title: Troubling outcomes from population-level analysis of surgery for upper tract urothelial carcinoma.
abstract: OBJECTIVE
  To review the surgical management of upper tract urothelial carcinoma (UTUC) on a population level. UTUC accounts for 5% of urothelial malignancies, making it less amenable to single-center reporting. Complete nephroureterectomy is the standard of care, and increasing evidence has shown that a suboptimal surgical technique is associated with an adverse prognosis.
  
  
  METHODS
  We obtained information for all patients diagnosed with UTUC (n = 830) and those treated surgically (n = 680) in the province of Ontario, Canada from the Ontario Cancer Registry from 1995 to 2004. Demographic, treatment, and vital status information was obtained for all patients, and pathology reports were available for 422 patients. The primary outcome was overall survival. The secondary outcomes included measures of surgical quality (ie, number of lymph nodes sampled, ureteral length excised, surgical margin status, and 30-day mortality) and disease-specific survival.
  
  
  RESULTS
  The unadjusted 5-year overall survival rate was 57.2%, with a median survival of 72.5 months. For those treated surgically, the 30-day mortality rate was 1.8%, and the positive surgical margin rate was 8.5%. Lymph nodes were identified in only 27% of the specimens, with a median yield of 1 (range 1-15). An estimated 25.8% of patients might have undergone incomplete ureteral resection at the time of nephroureterectomy.
  
  
  CONCLUSIONS
  UTUC is a lethal malignancy, with nearly one half the patients dying within 5 years. Furthermore, lymphadenectomy was rarely performed and approximately one fourth of patients might have undergone incomplete ureterectomy. The published outcomes from "centers of excellence" do not appear to reflect the surgical quality seen on a population level for this rare, but significant, malignancy.
authors.affiliation: Division of Urologic Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Abouassaly
authors.forename: Shabbir M H
authors.initials: SM
authors.lastname: Alibhai
authors.forename: Nasir
authors.initials: N
authors.lastname: Shah
authors.forename: Narhari
authors.initials: N
authors.lastname: Timilshina
authors.forename: Neil
authors.initials: N
authors.lastname: Fleshner
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
mesh_terms: D000368:Aged; D002173:Cancer Care Facilities / Q000706:statistics & numerical data; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000401:mortality / Q000601:surgery*; D008197:Lymph Node Excision / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000706:statistics & numerical data*; D009864:Ontario / Q000453:epidemiology; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D015996:Survival Rate; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000401:mortality / Q000601:surgery*