Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study.

The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories.

To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS).

This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017.

A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points.

A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU).

Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design.

We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.

European urology focus. 2021 Mar 24 [Epub ahead of print]

Gautier Marcq, Beat Foerster, Mohammad Abufaraj, Surena F Matin, Mounsif Azizi, Mohit Gupta, Wei-Ming Li, Thomas Seisen, Timothy Clinton, Evanguelos Xylinas, M Carmen Mir, Donald Schweitzer, Andrea Mari, Shoji Kimura, Marco Bandini, Romain Mathieu, Ja H Ku, Georgi Guruli, Markus Grabbert, Anna K Czech, Tim Muilwijk, Armin Pycha, David D'Andrea, Firas G Petros, Philippe E Spiess, Trinity Bivalacqua, Wen-Jeng Wu, Morgan Rouprêt, Laura-Maria Krabbe, Kees Hendricksen, Shin Egawa, Alberto Briganti, Marco Moschini, Vivien Graffeille, Riccardo Autorino, Patricia John, Axel Heidenreich, Piotr Chlosta, Steven Joniau, Francesco Soria, Phillip M Pierorazio, Shahrokh F Shariat, Wassim Kassouf

Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada; Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France., Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland., Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan., Department of Urology, MD Anderson Cancer Center, Houston, TX, USA., Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Department of Surgery, Division of Urology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Canada., Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA., Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan., Urology, GRC 5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France., Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA., Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Paris Descartes University, Paris, France., Instituto Valenciano de Oncologia Foundation, Valencia, Spain., Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands., Department of Urology, Careggi Hospital, University of Florence, Florence, Italy., Department of Urology, Jikei University School of Medicine, Tokyo, Japan., Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy., Department of Urology, University of Rennes, Rennes, France., Department of Urology, Seoul National University Hospital, Seoul, Korea., Division of Urology, Virginia Commonwealth University, Richmond, VA, USA., Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany., Department of Urology, Jagiellonian University Medical College, Krakow, Poland., Department of Urology, University Hospitals Leuven, Leuven, Belgium., Department of Urology, Provincial Hospital of Bozen, Bozen, Italy; Medical School, Sigmund Freud University, Vienna, Austria., Department of Urology, Medical University of Vienna, Vienna, Austria., Department of Urology, MD Anderson Cancer Center, Houston, TX, USA; Department of Urology and Kidney Transplant, The University of Toledo Medical Center and Eleanor N. Dana Cancer Center, Toledo, OH, USA., Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA., Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University Hospital Muenster, Muenster, Germany., Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland., Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Surgical Sciences, University of Torino School of Medicine, Turin, Italy., Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia., Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada. Electronic address: .