Specifically, it is worth noting that real-world practice may differ from guideline recommendations. Indeed, a shift toward shared decision-making and individualized treatment strategies was taking place, defining a new era of UTUC treatment.
Relying on a multicenter cohort of 72 patients,1 the current study represents one of the largest European experiences focusing specifically on HG eKSS-treated UTUC patients. Our findings suggest that eKSS may offer meaningful oncological control in selected patients, with two-year progression-free and recurrence-free survival rates of 79% and 82%, respectively. Notably, more than half of the patients were able to avoid or delay RNU for two years, highlighting the potential of eKSS as a strategy to defer radical surgery without immediate compromise in cancer control. Undoubtedly, an important aspect emerging from our analysis is the patient profile. The cohort was predominantly elderly and comorbid, with a median age of 78 years and a substantial burden of comorbidities, defined according to the Charlson Comorbidity Index (median CCI 3). In this setting, competing risks of mortality play a crucial role: the observed two-year other-cause mortality (20%) exceeded cancer-specific mortality (9%). Therefore, preserving renal function and minimizing surgical morbidity become key priorities.
Nonetheless, eKSS demonstrated a favorable perioperative profile, with low rates of major complications (<3%). This supports its feasibility even in frail populations. Moreover, the limited decline in renal function observed after eKSS further strengthens its role as a nephron-sparing alternative compared to RNU, which is known to significantly impact kidney function.
Key Findings
- Two-year progression-free and recurrence-free survival rates were 79% and 82%, respectively.
- Two-year CSM and OCM rates were 9% and 20%, respectively, suggesting that most patients died for cancer-unrelated causes.
- Tailored endoscopic surveillance strategies after eKSS are mandatory to ensure optimal oncological outcomes.
Overall, this study challenges the traditional paradigm that HG UTUC should invariably be managed with radical surgery. Instead, it suggests that in selected patients, particularly those who are elderly, comorbid, and with non-invasive disease, eKSS may represent a viable alternative to delay or even avoid RNU, without compromising short-term oncological outcomes.
Written by: Francesco Di Bello, Urology, Fundació Puigvert, Barcelona, Spain; Department of Neurosciences, Science of Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
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