(UroToday.com) The 2022 EAU annual meeting featured a session on new insights in the management of upper tract urothelial cancer, including a presentation by Dr. Francesco Del Giudice discussing contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy for upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy. New evidence indicates that minimally invasive surgery (laparoscopic or robotic-assisted nephroureterectomy) reaches oncologic equivalence compared with open radical nephroureterectomy for high-risk upper-tract urothelial carcinoma. Recently, the EAU Guidelines suggested implementing neoadjuvant chemotherapy to standard treatment to improve oncologic outcomes of high-risk upper-tract urothelial carcinoma. This study aimed to explore contemporary trends of minimally invasive surgery for radical nephroureterectomy in the United States (US) and to compare perioperative outcomes and costs with that of open radical nephroureterectomy. A secondary aim was to determine the trends of neoadjuvant chemotherapy and postoperative intravesical chemotherapy administration for high-risk upper-tract urothelial carcinoma and to assess their contribution to postoperative outcomes and costs.
The Optum Clinformatics® Data Mart de-identified database was queried from 2003 to 2018 to examine patients who had undergone laparoscopic/robotic-assisted nephroureterectomy or open radical nephroureterectomy with or without neoadjuvant chemotherapy and postoperative intravesical chemotherapy. Dr. Del Giudice and colleagues evaluated temporal adoption trends, complications, and health care cost analyses. Descriptive statistics and multivariable regression modeling was used to assess outcomes.
There were 492 patients (23.3%) undergoing open radical nephroureterectomy and 1,618 patients (76.7%) undergoing laparoscopic/robotic-assisted nephroureterectomy that were reviewed. The minimally invasive surgical approach was associated with a statistically significant lower risk of intraoperative complications (aOR 0.48, 95% CI 0.24–0.96), risk of hospitalization costs (aOR 0.62, 95% CI 0.49–0.78), and shorter hospital stay (aOR 0.20, 95%CI 0.15–0.26) when compared to open radical nephroureterectomy:
Overall, the adoption of neoadjuvant chemotherapy and postoperative intravesical chemotherapy accounted for only 81 (3.8%) and less than 37 cases (< 1.8%), respectively. The implementation of neoadjuvant chemotherapy and a higher number of cycles were associated with an increased probability of any complication rate (aOR 2.06, 95% CI 1.26–3.36) and hospital costs (aOR 2.12, 95% CI 1.33–3.38). Of note, minimally invasive surgeries for radical nephroureterectomy increased over the study period, while the number of open radical nephroureterectomies was stable:
Dr. Del Giudice noted several limitations of this study, including the data being administrative in nature, which relies on accurate coding of diagnoses and procedures. Second, procedures performed prior to access to insurance and entry into the database may not have been captured. Third, there was no staging or pathological information from the radical nephroureterectomy procedures available, which could limit the ability to assess the indication for neoadjuvant chemotherapy before surgery and oncological outcomes.
Dr. Del Giudice concluded his presentation by discussing contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy for upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy with the following take-home messages:
- Minimally invasive surgery has become the approach of choice for radical nephroureterectomy in the US, providing significant morbidity and health-related advantages compared to open radical nephroureterectomy
- Although recommended by guidelines, neither neoadjuvant chemotherapy nor postoperative bladder instillation of chemotherapy has been routinely incorporated into the clinical practice of patients with upper tract urothelial carcinoma
- Although a growing body of evidence suggests that neoadjuvant chemotherapy improves survival outcomes in patients with upper tract urothelial carcinoma, this research suggests that there is an increased perioperative risk and health cost profile for those who receive neoadjuvant chemotherapy
- Further prospective randomized studies are needed to balance the risk/benefit ratio of neoadjuvant chemotherapy in patients with high-risk upper tract urothelial carcinoma
Presented by: Francesco Del Giudice, Ph.D., Sapienza, University of Rome, Dept. of Maternal Infant and Urologic Sciences, Rome, Italy
Co-Authors: Stefanie V.U.2, Sciarra A.1, Salciccia S.1, Maggi M.1, Canale V.1, Flammia S.1, Viscuso P.1, Moriconi M.1, Pecoraro M.3, Panebianco V.3, Chung B.I.2
Affiliations: 1Sapienza, University of Rome, Dept. of Maternal Infant and Urologic Sciences, Rome, Italy, 2Stanford University School of Medicine, Dept. of Urology, Stanford, United States of America, 3Sapienza, University of Rome, Dept. of Radiology, Rome, Italy
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2022 European Association of Urology (EAU) Annual Hybrid Meeting, Amsterdam, NL, Fri, July 1 – Mon, July 4, 2022.