Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel

There is uncertainty regarding the oncologic effectiveness of kidney-sparing surgery (KSS) compared with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

To systematically review the current literature comparing oncologic outcomes of KSS versus RNU for UTUC.

A computerised bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting comparative oncologic outcomes of KSS versus RNU. Approaches considered for KSS were segmental ureterectomy (SU) and ureteroscopic (URS) or percutaneous (PC) management. Using the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, we identified 22 nonrandomised comparative retrospective studies published between 1999 and 2015 that were eligible for inclusion in this systematic review. A narrative review and risk-of-bias (RoB) assessment were performed using cancer-specific survival (CSS) as the primary end point.

Seven studies compared KSS overall (n=547) versus RNU (n=1376). Information on the comparison of SU (n=586) versus RNU (n=3692), URS (n=162) versus RNU (n=367), and PC (n=66) versus RNU (n=114) was available in 10, 5, and 2 studies, respectively. No significant difference was found between SU and RNU in terms of CSS or any other oncologic outcomes. Only patients with low-grade and noninvasive tumours experienced similar CSS after URS or PC when compared with RNU, despite an increased risk of local recurrence following endoscopic management of UTUC. The RoB assessment revealed, however, that the analyses were subject to a selection bias favouring KSS.

Our systematic review suggests similar survival after KSS versus RNU only for low-grade and noninvasive UTUC when using URS or PC. However, selected patients with high-grade and invasive UTUC could safely benefit from SU when feasible. These results should be interpreted with caution due to the risk of selection bias.

We reviewed the studies that compared kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma. We found similar oncologic outcomes for favourable tumours when using ureteroscopic or percutaneous management, whereas indications for segmental ureterectomy could be extended to selected cases of aggressive tumours.

European urology. 2016 Jul 28 [Epub ahead of print]

Thomas Seisen, Benoit Peyronnet, Jose Luis Dominguez-Escrig, Harman M Bruins, Cathy Yuhong Yuan, Marko Babjuk, Andreas Böhle, Maximilian Burger, Eva M Compérat, Nigel C Cowan, Eero Kaasinen, Joan Palou, Bas W G van Rhijn, Richard J Sylvester, Richard Zigeuner, Shahrokh F Shariat, Morgan Rouprêt

Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris; Pierre et Marie Curie Medical School, University Paris 6, Paris, France. Electronic address: ., Department of Urology, University of Rennes, Rennes, France., Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain., Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands., Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, ON, Canada., Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic., Department of Urology, HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany., Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany., Department of Pathology, Hôpital La Pitié-Salpétrière, UPMC, Paris, France., Radiology Department, Queen Alexandra Hospital, Portsmouth, UK., Department of Urology, Hyvinkää Hospital, Hyvinkää, Finland., Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain., Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands., European Association of Urology Guidelines Office, Brussels, Belgium., Department of Urology, Medical University of Graz, Graz, Austria., Medical University of Vienna, Vienna General Hospital, Vienna, Austria., Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris; Pierre et Marie Curie Medical School, University Paris 6, Paris, France.