Comparing Oncological and Perioperative Outcomes of Open versus Laparoscopic versus Robotic Radical Nephroureterectomy for the Treatment of Upper Tract Urothelial Carcinoma: A Multicenter, Multinational, Propensity Score-Matched Analysis

Critical care therapy and in-hospital mortality after radical nephroureterectomy for nonmetastatic upper urinary tract carcinoma

BACKGROUND

Use of critical care therapies (CCT), that include invasive mechanical ventilation (IMV), total parenteral nutrition (TPN) and other modalities are unknown after radical nephroureterectomy (RNU) for upper urinary tract carcinoma (UUTC). Their relationship with in-hospital mortality is also unknown.

METHODS

Within the National Inpatient Sample (2008-2019), we identified non-metastatic UUTC patients treated with RNU. Multivariable logistic regression models were used.

RESULTS

Of 8,995 patients, 375 (4.2%) received CCT and 82 (0.9%) experienced in-hospital mortality. Of CCT modalities, 215 (2.4%) received IMV and 139 (1.5%) TPN. Temporal CCT, IMV, and TPN trends very closely followed in-hospital mortality trends. Relative to historical UUTC patients (2008-2013), contemporary (2014-2019) patients exhibited lower CCT (Δ = 2.2%, P value < 0.0001), lower IMV (Δ = 1.4%, P < 0.0001), lower TPN (Δ = 2.2%, P < 0.0001), and lower in-hospital mortality (Δ = 0.4%, P = 0.03) rates. Of in-hospital mortalities, 52 out of 82 received CCT but 30 of 82 did not. Median age (> 72 years; odds ratio [OR] 1.4; P = 0.002) and Charlson comorbidity index ≥ 3 (OR 4.1; P < 0.001) and ≥ 1-2 (OR 1.7; P = 0.001) independently predicted overall higher CCT, IMV, TPN, and in-hospital mortality.

CONCLUSION

After RNU, CCT rates parallels in-hospital mortality rates. CCT represents a 5 to 6-fold multiple of in-hospital mortality rate. In RNU patients, CCT rates are higher in older and sicker individuals. Lower CCT rates that are paralleled by lower in-hospital mortality may be interpreted as an indicator of improved quality of care. Ideally all in-hospital mortalities should be predated by CCT exposure.

Perioperative and oncological outcomes of single position retroperitoneoscopic radical nephroureterectomy for upper urinary tract urothelial carcinoma

Radical nephroureterectomy (RNU) is the gold standard therapy for patients with upper urinary tract urothelial carcinoma (UTUC). In this study, we compared the effect of two surgical techniques, single-position complete retroperitoneoscopic radical nephroureterectomy (SCRNU) and laparoscopic nephroureterectomy with open bladder cuff excision (LNOBE), on perioperative and long-term oncological outcomes in UTUC patients. We retrospectively collected information on baseline characteristics, clinicopathological characteristics, surgical approaches, perioperative data, and survival outcomes from 174 patients who underwent RNU for UTUC between January 2018 and June 2023 in our center. The data were analyzed using the Mann-Whitney test, Fisher's exact test, Chi-square test. Linear regressions were applied to explore the effect of surgery approach on the continuous outcomes. Log-rank test and Kaplan-Meier survival curves were plotted to describe the survival outcome. Univariate and Multivariate Cox regressions were conducted to explore the independent prognostic factors. To address potential selection bias, we also employed an Inverse Probability of Treatment Weighting (IPTW) strategy. Patients who underwent SCRNU had shorter operative times (p < 0.001), reduced estimated blood loss (p < 0.001), less drainage on the first postoperative day (p = 0.009), shorter hospital stays (p = 0.001), and better intravesical recurrence-free survival than those who underwent LNOBE (IVRFS, HR: 0.17, 95% CI: 0.07-0.44, p = 0.007). Moreover, SCRNU was confirmed to be a protective factor for IVRFS after IPTW-adjusted Cox regression analysis was performed (HR: 0.17, 95% CI: 0.04-0.77, p = 0.021). SCRNU not only avoids intraoperative repositioning but also improves perioperative outcomes, including the reduction of operative time, blood loss, and length of hospital stay, and is associated with better IVRFS.

Intravesical Instillation of Chemotherapy Before Radical Surgery for Upper Urinary Tract Urothelial Carcinoma: The REBACARE Trial

BACKGROUND AND OBJECTIVE

Intravesical instillation of chemotherapy (IIC) after radical surgery for upper urinary tract urothelial carcinoma (UTUC) reduces the risk of intravesical recurrence (IVR). However, compliance is low because of possible extravesical leakage after bladder cuff excision. The aim of this study was to evaluate the efficacy of preoperative IIC in reducing the risk of IVR.

METHODS

In this prospective, single-arm, multi-institutional, phase 2 clinical trial, 190 chemonaïve patients with primary UTUC without prior or concurrent bladder cancer received a single intravesical instillation of mitomycin C for 1-2 hr within 3 h before surgery. The primary endpoint was the 2-yr histologically confirmed IVR rate, with a target reduction of >40% (from 33.2% according to literature data to <20%). A historical cohort of 247 patients with UTUC who did not receive perioperative IIC served as the reference. Secondary endpoints included compliance, toxicity, and IVR-free survival, which was analyzed via multivariable Cox regression and stratified by previous diagnostic ureteroscopy (d-URS).

KEY FINDINGS AND LIMITATIONS

The 2-yr IVR rate was 24% (95% confidence interval [CI] 18-31%) on intention-to-treat analysis and 23% (95% CI 13-32%) on per-protocol analysis. Multivariable analysis revealed that d-URS was associated with higher IVR risk. In the REBACARE cohort, patients without d-URS had threefold lower IVR risk (hazard ratio 0.33, 95% CI 0.12-0.87) in comparison to the reference cohort. Compliance with preoperative instillation was 96% and no grade >2 toxicity occurred.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Preoperative IIC with mitomycin C was feasible and well tolerated and significantly reduced IVR risk for patients without d-URS. These findings suggest that preoperative IIC is a viable strategy for this subset of UTUC patients and that d-URS should be performed judiciously.

In-Hospital Outcomes after Robotic Vs Open Radical Nephroureterectomy

Objective: To test whether the contemporary robot-assisted nephroureterectomy (RNU) is associated with more favorable in-hospital outcomes than historical RNU, relative to the same endpoints in open NU (ONU). Methods: Within the National Inpatient Sample (2008-2019), we identified RNU and ONU patients. Multivariable logistic and Poisson regression models were fitted. Results: Of 8032 NU patients, historical (2008-2013) vs contemporary (2014-2019) proportions were 776 (41%) vs 1104 (59%) for RNU and 3719 (60%) vs 2433 (40%) for ONU. The rates of RNU have increased over time (2008-2019; Δ absolute: +18%; p < 0.001). Contemporary RNU patients exhibited significantly better in-hospital outcomes in 6 of 12 comparisons vs historical that ranged from -54% for genitourinary complications to -12% for median length of stay (LOS). Contemporary ONU patients also exhibited significantly better in-hospital outcomes in 11 of 12 comparisons vs historical that ranged from -67% for blood transfusions to -26% for gastrointestinal complications. When historical RNU was compared with historical ONU, RNU in-hospital outcomes were better in 7 of 12 comparisons that ranged from -61% for median LOS to -16% for postoperative complications. Conversely, when contemporary RNU was compared with contemporary ONU, RNU in-hospital outcomes were only better in 2 of 12 comparisons: -25% cardiac complications and -13% for median LOS. Conclusion: The magnitude of in-hospital outcomes categories improvement between historical vs contemporary was two-fold more pronounced in ONU (11 improved categories) than in RNU (6 improved categories). Few outcome benefits remained (two categories only) when contemporary RNU was compared with contemporary ONU.

Gold standard nephroureterectomy, chemoprophylaxis and surveillance in upper tract urothelial carcinoma

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence on surgical management, strategies to reduce tumor recurrence, and surveillance regimens in patients diagnosed with upper tract urothelial carcinoma (UTUC) and elected for radical treatment.

RECENT FINDINGS

Minimally invasive surgery is gaining momentum in the surgical management of UTUC. Chemoprophylaxis is still the gold standard to reduce intravesical recurrence after radical nephroureterectomy (RNU). Novel surveillance strategies have been proposed to adapt follow-up regimens to patients' characteristics.

SUMMARY

Minimally invasive surgery has been associated with comparable oncological outcomes to the open approach while improving postoperative morbidity. In these cases, bladder cuff excision (BCE) is mostly performed by an extravesical approach, that demonstrates a noninferiority compared to the intravesical one in terms of oncological outcomes. Although lymphadenectomy is recommended in patients with high-risk tumors, its benefits are still unclear. Currently, there is a lack of recent prospective trials on chemoprophylaxis to reduce intravesical recurrence post RNU, making single-dose postoperative chemotherapy instillation the standard treatment. Although novel risk stratification models were released by international urological guidelines, their validity is mainly nonevidence-based. Risk-adapted follow-up strategies incorporating cystoscopy and cross-sectional imaging accounting for individual patient factors should be implemented.

French AFU Cancer Committee Guidelines - Update 2024-2026: Upper urinary tract urothelial cancer (UTUC)

INTRODUCTION

The purpose of this study was to propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search for epidemiology, risk factors, diagnosis, prognosis, treatment options and follow-up of UTUC was performed between 2022 and 2024 to evaluate available references and their levels of evidence.

RESULTS

UTUC is a rare malignancy with specific risk factors, including exposure to aristolochic acid and Lynch syndrome. Its diagnosis is based on the use of computed tomography urography and ureterorenoscopy with biopsies. A prognostic classification has been proposed to discriminate low- and high-risk lesions mainly on the basis of tumour grade (low/high) and imaging aspects (non-invasive/invasive). Tumour size (<2/≥2cm), focality (uni-/multifocal), and hydronephrosis (absent/present) are more relative risk factors. The standard of care for low-risk patients is currently conservative treatment involving ureterorenoscopy laser ablation, whereas radical nephroureterectomy (RNU) is advised for those with high-risk disease. Adjuvant treatments after RNU include intravesical instillation of chemotherapy to decrease the risk of bladder recurrence and delivery of platinum-based chemotherapy in pT2-T4 and/or pN+ patients. First-line treatment for metastatic UTUC is based on the combination of enfortumab vedotin plus pembrolizumab. For unfit patients, platinum-based chemotherapy plus nivolumab followed by maintenance nivolumab or platinum-based chemotherapy followed by maintenance avelumab in those with at least stable disease can be proposed. The surveillance regimen and schedule depend on the disease stage.

CONCLUSION

These updated guidelines will contribute to improving the management of patients diagnosed with UTUC.

Laparoscopic Versus Open Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-Analysis of Propensity-Score Matched Studies

BACKGROUND

The effectiveness of laparoscopic nephroureterectomy (LNU) vs open nephroureterectomy (ONU) for upper tract urothelial carcinoma (UTUC) is unclear.

METHODS

We conducted a meta-analysis of studies based on propensity score-matched cohorts to compare the surgical and oncological outcomes of LNU and ONU in UTUC patients. A literature search was conducted on PubMed, Embase, and Cochrane Library until July 12, 2023. The Newcastle-Ottawa Scale was utilized to assess the quality of eligible studies. Measurements of surgical and oncological outcomes were extracted and pooled including mean difference (MD), risk ratio (RR), hazard ratios (HR), and 95% confidence intervals (CI).

RESULTS

Five high-quality retrospective studies were included, totaling 6422 patients; 2080 (32.4%) underwent LNU, and 4342 (67.6%) underwent ONU. With respect to surgical outcomes, patients in the LNU group experienced less estimated blood loss and had shorter hospital stay than those in the ONU group, but there was no significant difference in complication rates and operation time. In regard to oncological outcomes, there were no significant differences between the LNU and ONU groups in 3-year overall survival (OS) and cancer-specific survival (CSS). However, 3-year intravesical recurrence free survival (IVRFS) was worse in the LNU group compared to the ONU group.

CONCLUSION

LNU was associated with less estimated blood loss and shorter hospital stays than ONU, but there were no differences in OS and CSS between the surgical modalities. Nonetheless, LNU might result in poorer IVRFS than ONU.

A narrative review of advances in the management of urothelial cancer: Diagnostics and treatments

Urothelial carcinoma (UC) refers to the malignancies originating from transitional epithelium located on the upper and lower urinary tract. Precise diagnosis of UC is crucial since it dictates the treatment efficacy and prognosis of UC patients. Conventional diagnostic approaches of UC mainly fall into four types, including liquid biopsy, imaging examination, endoscopic examination, and histopathological assessment, among others, each of them has contributed to a more accurate diagnosis of the condition. Therapeutically, UC is primarily managed through surgical intervention. In recent years, minimally invasive surgery (MIS) has been incrementally used and is showing superiority in terms of lowered perioperative morbidity and quicker recovery with similar oncological outcomes achieved. For advanced UC (aUC), medical therapy is dominant. While platinum-based chemotherapies are the standard first-line option for aUC, some novel treatment alternatives have recently been introduced, such as immune checkpoint inhibitors (ICIs), targeted therapies, and antibody-drug conjugates (ADCs). ADCs, a group of sophisticated biopharmaceutical agents consisting of monoclonal antibodies, cytotoxic payload, and linker, have been increasingly drawing the attention of clinicians. In this review, we synthesize the recent developments in the precise diagnosis of UC and provide an overview of the treatment options available, including MIS for UC and emerging medications, especially ADCs of aUC.

Open versus minimally invasive nephroureterectomy in octogenarians: An analysis of surgical approach trends, outcomes, and survival analysis with propensity matching

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) is a rare disease accounting only for 5%-10% of urothelial carcinoma (UC). For localized high-risk disease, radical nephroureterectomy (RNU) is the standard of care. While minimally invasive (MIS) RNU has not been shown to decisively improve overall survival (OS) compared to open surgery, MIS RNU has been associated with reduced hospital length of stay (LOS), blood transfusion requirements and improved recovery, which are important considerations when treating older patients. The purpose of this study is to examine trends in surgical approach selection and outcomes of open vs. MIS RNU in patients aged ≥80 years.

METHODS

Using the National Cancer Database (NCDB), patients aged ≥80 years who underwent open or MIS (either robotic or laparoscopic) RNU were identified from 2010 to 2019. Demographic, patient-related, and disease-specific factors associated with either open or MIS RNU were assessed using multivariate logistic regression models. Survival analysis was conducted using Kaplan-Meier plots and Cox-proportional hazard regression. Inverse probability of treatment weighting (IPTW) was utilized to adjust for confounding variables. Survival analysis was also conducted on the IPTW adjusted cohort using Kaplan-Meier plots and Cox-proportional hazard regression.

RESULTS

5,687 patients were identified, with 1,431 (25.2%) and 4,256 (74.8%) patients undergoing open and MIS RNU respectively. The proportion of RNU performed robotically has increased from 12.5% in 2010 to 50.4% in 2019. MIS was associated with a shorter hospital LOS (4.7 days versus 5.9 days, SMD 23.7%). Multivariate analysis revealed that MIS was associated with a significant reduction in 90-day mortality (OR: 0.571; 95%CI: 0.34-0.96, P = 0.033) and improved median OS (53.8 months [95%CI: 50.9-56.9] vs 42.35 months [95%CI: 38.6-46.8], P < 0.001) compared to open surgery. IPTW-adjusted survival analysis revealed improved median OS with MIS when compared to open surgery, with a survival benefit of 46.1 months (95%CI: 40.2-52.4 months) versus 37.7 months (95%CI: 32.6-46.5 months, P = 0.0034) respectively. IPTW-adjusted cox proportional hazard analysis demonstrated that MIS was significantly associated with reduced mortality (HR 0.76, 95%CI: 0.66-0.87, P < 0.001).

CONCLUSION

In octogenarians undergoing RNU, MIS is associated with improved median OS and 90-day mortality.

Adoption of robot-assisted radical nephroureterectomy permits a minimally invasive option for management of upper tract urothelial carcinoma in geriatric patients: comparison with non-geriatric patients with intermediate-term oncologic follow-up

To assess the oncologic efficacy and safety of robot-assisted approach to radical nephroureterectomy (RARNU) in geriatric versus younger patients with upper tract urothelial carcinoma (UTUC). A single-center, retrospective cohort study was conducted from 2009 to 2022 of 145 patients (two cohorts: < 75 and ≥ 75 years old) with non-metastatic UTUC who underwent RARNU. Primary endpoint was UTUC-related recurrence of disease during surveillance (bladder-specific and metastatic). Safety was assessed according to 30-day, modified Clavien-Dindo (CD) classifications (Major: C.D. III-V). Survival estimates were performed using Kaplan-Meier method. There were 89 patients < 75 years (median 65 years) and 56 patients ≥ 75 years (median 81 years). Comparing the young versus geriatric cohorts: median follow-up 38 vs 24 months (p = 0.03, respectively) with similar 3-year bladder-specific recurrence survival (60% vs 67%, HR 0.70, 95% CI [0.35, 1.40], p = 0.31) and metastasis-free survival (79% vs 70%, HR 0.71, 95% CI [0.30, 1.70], p = 0.44). Expectedly, the younger cohort had a significant deviation in overall survival compared to the geriatric cohort at 1-year (89% vs 76%) and 3-years (72% vs 41%; HR 3.29, 95% CI [1.88, 5.78], p < 0.01). The 30-day major (1% vs 0) and minor complications (8% vs 14%, p = 0.87). Limitations include retrospective study design of a high-volume, single-surgeon experience. Compared to younger patients with UTUC, geriatric patients undergoing RARNU have similar oncologic outcomes at intermediate-term follow-up with no increased risk of 30-day perioperative complications. Thus, age alone should not be used to disqualify patients from definitive surgical management of UTUC with RARNU.