title: Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma.
abstract: Lymph node dissection (LND) performed during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains controversial and difficult to evaluate. The aim of this study was to investigate whether removal of more lymph nodes during RNU is safe and improves oncologic outcomes.
  
  
  
  We evaluated 422 patients who underwent RNU with concomitant LND for upper tract urothelial carcinoma between 1976 and 2015, assessing for an association between total nodes removed, recurrence-free survival, and cancer-specific survival using Cox proportional hazards models. We also investigated the relationship between nodal yield and perioperative metrics and intersurgeon variability using linear regression.
  
  
  
  In our cohort of 442 patients, 239 developed recurrences and 94 patients died of disease. Median follow-up among survivors was 3.7 years (interquartile range: 1.2, 7.4). The median nodal yield was 9 (interquartile range: 4, 16). Among patients with node-positive disease (pN1), we observed a significant improvement in recurrence-free survival (hazard ratio = 0.84 per 5 nodes removed, P = 0.039) and a nonsignificant improvement in cancer-specific survival with an increase in the nodal yield (hazard ratio = 0.90 per 5 nodes removed, P = 0.2). There was no evidence of an association between node yield and operative time, estimated blood loss, or 30-day complications on multivariable analysis. There was significant heterogeneity among surgeons regarding the extent of LND (P<0.0001).
  
  
  
  We found that a more extensive node dissection may improve oncologic outcomes in a subset of high-risk patients without significantly increasing operative time or serious complications. Additionally, we identified considerable intersurgeon heterogeneity regarding the extent of LND furthering the notion of surgeon variability as a nonstandardized factor.
authors.affiliation: SUNY Downstate College of Medicine and Kings County Hospital Center, Brooklyn, NY.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Winer
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Vertosick
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
authors.forename: Mazyar
authors.initials: M
authors.lastname: Ghanaat
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
authors.forename: Renato B
authors.initials: RB
authors.lastname: Corradi
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY; Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Sigrid
authors.initials: S
authors.lastname: Carlsson
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Sjoberg
authors.affiliation: Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, New York City, NY.
authors.forename: Alexander I
authors.initials: AI
authors.lastname: Sankin
authors.affiliation: Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY.
authors.forename: John P
authors.initials: JP
authors.lastname: Sfakianos
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
authors.forename: Eugene K
authors.initials: EK
authors.lastname: Cha
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY. Electronic address: colemanj@mskcc.org.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Coleman
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D000074682:Nephroureterectomy; D011379:Prognosis; D015996:Survival Rate; D014571:Urologic Neoplasms / Q000473:pathology / Q000601:surgery*
keywords: Complications; Extent of lymph node dissection; Oncologic outcomes; UTUC; Upper tract urothelial carcinoma