Patient Outcomes After Concurrent Radical Cystectomy and Nephroureterectomy - Expert Commentary

Primary bladder malignancy accounts for up to 95% of urothelial carcinomas (UC), and upper tract urothelial carcinoma (UTUC) accounts for the rest of UC cases. Radical cystectomy (RC) is the typical treatment for aggressive UC, while radical nephroureterectomy (RNU) is the treatment of choice for aggressive UTUC. Some patients with UC require simultaneous RC and RNU due to concurrent pathologies in the upper tract or kidney dysfunction.


A recent study by Carpinito et al. compiled medical data from 27 patients with bladder cancer who underwent simultaneous RC and RNU between 2006 and 2020. Of the selected cohort, 81% were male, and the median age was 71. Approximately half of the patients had a prior diagnosis of non-muscle-invasive bladder cancer. UTUC was the indication for RNU in twelve patients, while in the remaining fifteen patients, it was a non-functional kidney. Eleven patients (41%) were rendered anephric. The median length of postoperative stay was six days. Two patients died shortly after surgery: one from myocardial infarction and the second from sepsis due to infection at the surgical site. There was no significant difference in postoperative complications between patients who were rendered anephric and those who were not. The median follow-up duration was 36 months, and 52% of patients were alive at the last follow-up. Overall, the mortality rate within 90 days of the surgery was 7%. The median survival was 47 months, and the 5-year overall survival was 42%. The median duration of progression-free survival was 30 months, and 5-year progression-free survival was 41%. Finally, 2% of male patients had a urethral recurrence requiring subsequent urethrectomy.

One patient had pre-operative clinical node-positive status, while seven patients had node-positive status on final pathology, two of whom had received neoadjuvant chemotherapy. Interestingly, three patients who had non-functional kidneys before the procedure were found to have occult UTUC on final pathology.

This study shows that simultaneous RC and RNU can be safely performed in most patients with appropriate indications. High rates of occult UTUC in non-functional kidneys and subsequent urethral recurrence were observed. Collaborative efforts to collect data on these cases from multiple institutions will be needed to assemble larger cohorts to validate these findings.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine, New York City, New York

References:

  1. Carpinito, G. P., Cook, G. S., Tverye, A. N., Gold, S. A., Lotan, Y., Margulis, V., & Howard, J. M. (2022). Outcomes of patients undergoing concurrent radical cystectomy and nephroureterectomy: A single-institution series. Canadian Urological Association Journal. Advance online publication. https://doi.org/10.5489/cuaj.7612.
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