title: Ureteroscopic and extirpative treatment of upper urinary tract urothelial carcinoma: a 15-year comprehensive review of 160 consecutive patients.
abstract: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UTUC) have historically been treated with radical, extirpative surgery, primarily nephroureterectomy with bladder-cuff excision. In general, there has been growing interest in renal preservation, as evidenced by the broadening application of nephron-sparing surgery for renal parenchymal tumours. Beyond imperative reasons such as tumour in a solitary kidney, bilateral disease, or comorbidities preventing radical surgery, there is a growing role for endoscopic management of upper tract tumours. The aim has been to obtain similar oncological results to those of extirpative surgery, while preserving long-term renal function. Properly selecting patients for these therapies, designing specific treatments based on a complex presentation, and general information with regard to outcomes and risks for patient counselling have been based historically on results from relatively small series without long-term follow-up. This study reflects all patients with UTUC treated by a single tertiary referral surgeon, accrued prospectively over 15 years using the same surgical techniques and treatment algorithms throughout the entire study period, with 10-year survival data. The consecutively accrued nature and size of the study groups, uniformity in treatments, statistical review and long-term follow-up provide baseline oncological data that could help frame future study.
  
  
  OBJECTIVE
  • To present long-term oncological outcomes of all patients treated surgically for upper urinary tract urothelial carcinoma (UTUC) over a 15-year period.
  
  
  METHODS
  • All patients (N = 160) treated from January 1996 to August 2011 were prospectively studied and placed into three distinct groups after initial diagnostic ureteroscopy (URS): Group 1: low grade lesions treated with URS (n = 66); Group 2: high grade lesions palliatively treated with URS (n = 16); and Group 3: extirpative surgery (nephroureterectomy [NU]; n = 80). • Statistical analysis was performed using Kaplan-Meier methodology to calculate overall (OS), cancer-specific (CSS) and metastasis-free survival (MFS).
  
  
  RESULTS
  • The median patient age at presentation was 73 years, and the mean (range) follow-up time was 38.2 (1-185) months. At initial diagnostic URS, 71 (44.4%) patients presented with high grade and 89 (55.6%) patients presented with low grade disease. • The 2-, 5- and 10-year CSS rates were 98, 87 and 81% for patients with low grade disease, and 97, 87 and 78% for patients treated with URS (Group 1), not significantly different from those patients with low grade disease treated with NU (Group 3), (P = 0.54). • Of the patients treated with URS for low grade disease, 10 (15.2%) progressed to high grade disease at a mean time of 38.5 months. • Patients with high grade disease treated with NU had a 2-, 5-, and 10-year CSS of 70, 53 and 38%, with a MFS of 55, 45 and 35%. • Median survival of patients with high grade disease treated with palliative URS was 29.2 months with a 2-year OS of 54%. • On multivariate analysis only high grade lesion on initial presentation was found to be a significant factor (P < 0.001; hazard ratio = 7.27).
  
  
  CONCLUSIONS
  • Grade is the most significant predictor of OS and CSS in those with UTUC, regardless of treatment method. • Ureteroscopic and extirpative therapy are acceptable options for those with low grade disease showing excellent long-term CSS. • Extirpative therapy was found to result in relatively poor long-term CSS in patients with high grade disease, underscoring the need for adjuvant or neoadjuvant therapies.
authors.affiliation: Department of Urology, New York Medical College, Valhalla, New York, USA. Mgrasso3@earthlink.net
authors.forename: Michael
authors.initials: M
authors.lastname: Grasso
authors.forename: Andrew I
authors.initials: AI
authors.lastname: Fishman
authors.forename: Jacob
authors.initials: J
authors.lastname: Cohen
authors.forename: Bobby
authors.initials: B
authors.lastname: Alexander
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D018450:Disease Progression; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000209:etiology; D009392:Nephrectomy / Q000379:methods*; D010166:Palliative Care / Q000379:methods; D011446:Prospective Studies; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000601:surgery*; D018666:Ureteroscopy / Q000379:methods*; D001749:Urinary Bladder Neoplasms / Q000556:secondary