title: Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study.
abstract: What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT-UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the 'gold-standard' treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT-UCs. Due to the paucity of cases of UUT-UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi-institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5-year probability of cancer-specific survival, recurrence-free survival and metastasis-free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases.
  
  
  OBJECTIVE
  To compare recurrence-free survival (RFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT-UC) located in the ureter.
  
  
  METHODS
  We performed a multi-institutional retrospective review of patients with UUT-UC who had undergone RNU or SU between 1995 and 2010. Type of surgery, Tumour-Node-Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival.
  
  
  RESULTS
  In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow-up was 26 (10-48) months. The 5-year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P = 0.99); 37% and 47.9%, respectively (P = 0.48); 81.9% and 85.4%, respectively (P = 0.51). In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P = 0.94, 0.42 and 0.53, respectively). In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P = 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P = 0.001, 0.04, 0.009 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of the disease.
  
  
  CONCLUSIONS
  Short-term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases and should be considered an option. In every other case, RNU still represents the 'gold standard' for the treatment of UUT-UC.
authors.affiliation: Academic Department of Urology, CHRU Lille, Univ Lille Nord de France, Lille, France. pierre_colin@msn.com
authors.forename: Pierre
authors.initials: P
authors.lastname: Colin
authors.forename: Adil
authors.initials: A
authors.lastname: Ouzzane
authors.forename: Géraldine
authors.initials: G
authors.lastname: Pignot
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ravier
authors.forename: Sébastien
authors.initials: S
authors.lastname: Crouzet
authors.forename: Mehdi M
authors.initials: MM
authors.lastname: Ariane
authors.forename: Marie
authors.initials: M
authors.lastname: Audouin
authors.forename: Yann
authors.initials: Y
authors.lastname: Neuzillet
authors.forename: Baptiste
authors.initials: B
authors.lastname: Albouy
authors.forename: Sophie
authors.initials: S
authors.lastname: Hurel
authors.forename: Fabien
authors.initials: F
authors.lastname: Saint
authors.forename: Julien
authors.initials: J
authors.lastname: Guillotreau
authors.forename: Laurent
authors.initials: L
authors.lastname: Guy
authors.forename: Pierre
authors.initials: P
authors.lastname: Bigot
authors.forename: Alexandre
authors.initials: A
authors.lastname: De La Taille
authors.forename: Frédéric
authors.initials: F
authors.lastname: Arroua
authors.forename: Charles
authors.initials: C
authors.lastname: Marchand
authors.forename: Alexandre
authors.initials: A
authors.lastname: Matte
authors.forename: Pierre O
authors.initials: PO
authors.lastname: Fais
authors.forename: Morgan
authors.initials: M
authors.lastname: Rouprêt
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology / Q000556:secondary / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009392:Nephrectomy; D015996:Survival Rate; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*