AUA 2021: Perioperative Intravesical Chemotherapy in Minimally Invasive Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Low but Increasing Utilization Worldwide

(UroToday.com) In this abstract presented by Alexander Kenigsberg and colleagues, at the American Urologic Association (AUA) annual meeting, the authors evaluated the usage of intravesical chemotherapy in the perioperative setting following radical nephroureterectomy for upper tract urothelial carcinoma. While utilization remains low, they note that usage is increasing worldwide.


They note that there is level one evidence that has demonstrated that perioperative intravesical chemotherapy (IVC) at or around the time of radical nephroureterectomy (RNU) reduces the risk of intravesical recurrence. Guideline statements since 2013 have recommended its use.1 While many have suggested low utilization of this intervention, but little had been published on the topic. The authors address this deficiency by examining the utilization of IVC over time and determine predictors of its administration.

They collected data from 17 high-volume academic centers, focusing on patients who underwent RNU between 2006 and 2020. Patients who underwent robotic or laparoscopic RNU without concomitant radical cystectomy were included. Cases in which IVC administration details were unknown were excluded. *This was not clear to me why. Baseline data were analyzed with univariate analyses and a multivariable logistic regression utilized to determine predictors of IVC at time of RNU. They completed a trend analysis to evaluate IVC utilization by year.

They identified 870 patients, of whom 659 of whom met inclusion criteria. 512 did not receive IVC while 147 did. Non-IVC patients were older (p<0.001), had higher ECOG scores (p=0.003), more likely to have multifocal disease (23% versus 12%, p=0.005). Those in the IVC group were more likely to have higher clinical T stage disease (p=0.008), undergone laparoscopic RNU (83% vs 68%, p<0.001), and more likely to have undergone endoscopic management of the bladder cuff (20% vs 4%, p=0.008).

When looking at predictors of administration, multivariable regression models demonstrated that decreased age (OR 0.94, p<0.001), Asian race (OR 3.584, p<0.001), laparoscopic approach (OR 2.421, p=0.006), and endoscopic management of the bladder cuff (OR 7.694, p<0.001) were all significant predictors favoring IVC administration.

  • This did not make sense to me, especially the laparoscopic approach and endoscopic approach. I would have expected a robotic approach and robotic closure of the cuff to predict IVC administration.

Treatment at a European Center was also associated with a lower rate of IVC use.

Looking at trends of utilization, overall utilization of IVC after the 2013 European Association of Urology (EAU) guideline was 24% versus 0% prior to 2013 (p<0.001), Figure 1.

intravesical chemotherapy-0.jpg  
It also looks to be increasing proportionally year over year. However, it should be noted that the numbers from 2019 and 2020 seem to be limited.

Based on this study of the academic centers, perioperative IVC use has increased since being added to the EAU upper tract urothelial carcinoma guidelines, but use remains low even at high volume academic centers. We can only assume it's less in the general practice/community. Further studies are needed to optimize regimens to encourage IVC use.

Presented by: Alexander P. Kenigsberg, MD, UT Southwestern Urology

Written by: Thenappan (Thenu) Chandrasekar, MD – Urologic Oncologist, Assistant Professor of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, @tchandra_uromd on Twitter the 2021 American Urological Association, (AUA) Annual Meeting, Fri, Sep 10, 2021 – Mon, Sep 13, 2021.

References:

  1. Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester R, Burger M, Cowan N, Böhle A, Van Rhijn BW, Kaasinen E, Palou J, Shariat SF; European Association of Urology. European guidelines on upper tract urothelial carcinomas: 2013 update. Eur Urol. 2013 Jun;63(6):1059-71. doi: 10.1016/j.eururo.2013.03.032. Epub 2013 Mar 19. PMID: 23540953.
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