Risk of Recurrence and Progression after Endoscopic Kidney-sparing Surgery for Upper Tract Urothelial Carcinoma

The adoption of novel endourological technologies and the growing evidence of favorable oncological outcomes in selected patients led to an increasing use of endoscopic kidney-sparing surgery (eKSS) for upper tract urothelial carcinoma (UTUC). Current European Association of Urology (EAU) guidelines recommend stratifying patients according to the risk of progression to ≥pT2 or non–organ-confined disease (low-risk vs. high-risk). However, real-world clinical scenarios often challenge this classification.

For example, a patient may present with a small (<2 cm), solitary, high-grade (HG) tumor located in the renal pelvis, while having good performance status and preserved renal function. According to EAU criteria, high-grade histology alone categorizes this patient as high-risk and favors radical nephroureterectomy (RNU). This raises important clinical questions: are we overtreating such patients? Are we unnecessarily compromising future renal function? Furthermore, how should management be adapted in patients with pan-urothelial disease? Does the presence of synchronous bladder cancer (BCA) alter clinical decision-making?

These considerations underscore the need for more clinically nuanced classifications. In this context, the present study aimed to develop a novel classification system to predict both recurrence and progression after eKSS.¹
Using data from a UTUC registry, a retrospective, multicenter database maintained by the Young Academic Urologists (YAU) Urothelial Group, the authors analyzed outcomes in patients treated with eKSS. The study included 223 UTUC patients with organ-confined disease (no evidence of local extension on computed tomography) who underwent eKSS and were followed for more than 3 months.

Key Findings

Several prognostic factors for recurrence and progression following eKSS were identified, including the presence of synchronous bladder cancer.
A novel scoring system was developed that stratifies patients into three distinct risk groups, with meaningful implications for patient counseling and treatment selection.
Five-year cumulative incidence rates for recurrence in the low-, intermediate-, and high-risk groups were 37%, 58%, and 70%, respectively, while corresponding progression rates were 4%, 18%, and 30%.

Clinical Implications and Conclusions

The findings support the existence of an intermediate-risk UTUC category with outcomes that are clearly distinct from traditional low- and high-risk groups. Incorporating this intermediate-risk group into clinical practice may improve risk stratification and aid in selecting patients who could safely benefit from kidney-sparing approaches. Prospective validation in larger cohorts is required to confirm these results and refine treatment algorithms.

Written by: Francesco Di Bello, MD, University of Naples Federico II, Naples, Italy; Fundaciò Puigvert, Barcelona, Spain

Reference:

Gallioli A, Di Bello F, Zattoni F, D’Andrea D, Laukhtina E, Soria F, et al. Risk of Recurrence and Progression After Endoscopic Kidney-sparing Surgery for Upper Tract Urothelial Carcinoma. Eur Urol Oncol. 24 gennaio 2026;S2588-9311(26)00003-9.

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