title: Renal function and oncologic outcomes of parenchymal sparing ureteral resection versus radical nephroureterectomy for upper tract urothelial carcinoma.
abstract: OBJECTIVE
  We compared renal function and oncologic outcomes of parenchymal sparing ureteral resection with radical nephroureterectomy for the treatment of upper tract urothelial carcinoma confined to the ureter.
  
  
  METHODS
  Review of a large institutional database identified 367 patients treated for primary upper tract urothelial carcinoma with radical nephroureterectomy or parenchymal sparing ureteral resection from 1994 to 2009. Patients with known renal pelvis tumors, muscle invasive urothelial carcinoma, prior cystectomy, contralateral upper tract urothelial carcinoma, metastatic disease or chemotherapy were excluded, leaving 120 patients for analysis. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Recurrence-free, cancer specific and overall survival were estimated using Kaplan-Meier analysis.
  
  
  RESULTS
  Radical nephroureterectomy was performed in 87 patients and parenchymal sparing ureteral resection in 33. Median age at surgery was 73 years in the radical nephroureterectomy group (IQR 64-76) vs 70 years (IQR 59-77) in the parenchymal sparing ureteral resection group (p = 0.5). The radical nephroureterectomy and parenchymal sparing ureteral resection cohorts had several disparate clinicopathological variables including preoperative hydronephrosis (80% vs 45%, p = 0.0006), stage (pT3 or greater 26% vs 9%, p = 0.01) and baseline estimated glomerular filtration rate (51 vs 63 ml/minute/1.73 m(2), p = 0.009). Patients who underwent radical nephroureterectomy experienced a significantly greater decrease in estimated glomerular filtration rate after surgery (median -7 vs 0 ml/minute/1.73 m(2), p <0.001). Median followup was 4.2 years. Of the patients 79 experienced cancer recurrence and 44 died (28 of upper tract urothelial carcinoma). There were no obvious differences in the rates of recurrence, cancer specific death or overall death by procedure type. However, due to the limited number of events we cannot exclude the possibility that there are large differences in oncologic outcomes by procedure type.
  
  
  CONCLUSIONS
  Parenchymal sparing ureteral resection is associated with superior postoperative renal function. However, the impact on cancer control cannot be determined conclusively due to the small sample size and putative selection bias.
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. silbersj@mskcc.org
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Silberstein
authors.forename: Nicholas E
authors.initials: NE
authors.lastname: Power
authors.forename: Caroline
authors.initials: C
authors.lastname: Savage
authors.forename: Tatum V
authors.initials: TV
authors.lastname: Tarin
authors.forename: Ricardo L
authors.initials: RL
authors.lastname: Favaretto
authors.forename: Daniel
authors.initials: D
authors.lastname: Su
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Kaag
authors.forename: Harry W
authors.initials: HW
authors.lastname: Herr
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000503:physiopathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D007668:Kidney / Q000503:physiopathology*; D007677:Kidney Function Tests; D007680:Kidney Neoplasms / Q000503:physiopathology* / Q000601:surgery; D008297:Male; D009392:Nephrectomy / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000503:physiopathology* / Q000601:surgery*