BERKELEY, CA (UroToday.com) - The incidence of new-onset chronic kidney disease (glomerular filtration rate (GFR) < 60 ml/minute) following nephrectomy approaches 65%.
Decreased GFR after radical nephroureterectomy (RNU) may contribute to sub-optimal regimens and infrequent utilization of adjuvant chemotherapy for upper tract urothelial carcinoma. It is therefore imperative to preoperatively identify patients who may benefit from systemic therapy prior to RNU when renal function is maximal. Alternatively, glomerular preservation with partial ureterectomy (PU) in appropriately selected patients is an attractive alternative to RNU. We report the largest comparison, to date, of a contemporary, international cohort of patients treated with either RNU or PU for the management of UTUC.
Of the more than 1 200 patients in the original Upper Tract Urothelial Carcinoma Colloaboration, 835 had operations classified as either 1) RNU or 2) PU. This subgroup comprised our study cohort. Groups were compared based on type of surgery (RNU vs PU). Fisher’s exact test and chi-square tests were used to evaluate the association between groups and clinic-pathologic parameters. Outcomes were measured by time to disease recurrence or to cancer-specific mortality from time of surgery. Univariable recurrence and survival probabilities were analyzed with Kaplan-Meier analyses. Cox regression models with known predictors of outcomes and incorporation of surgery type addressed cancer-specific mortality after surgery.
Eighty-one patients (9.7%) received partial ureterectomy and 754 (90.3%) received RNU. Two hundred thirty-eight patients experienced systemic (8.9%) and/or local disease progression (19.6%) after surgery. One hundred eighty patients (21.6%) died from UTUC. All-cause mortality was 30.2%. Five-year survival probabilities for RFS (69.4% vs. 75.9%, p=0.06) and CSS (67.5% vs. 72.1%, p=0.06) were not significantly different between PU and RNU. Analyzing only patients with ureteral tumors, Kaplan-Meier 5-year survival probabilities for RFS (59.5% vs. 70.9%, p=0.53) and CSS (67.4% vs. 73%, p=0.21) were not significantly worse for PU than RNU. In the subgroup of patients with < pT2 tumors, 3 year CSS probabilities for PU and RNU did not significantly differ (78.9% vs. 85.9%, p=0.25, respectively). Similarly, 3 year CSS probabilities for T3/T4 tumors receiving RNU (51.5%) and PU (52.5%) were not statistically different (p=0.85). More patients in the RNU arm received neoadjuvant chemotherapy (5.6% vs. 0%, p=0.02) than the PU cohort, respectively. However, significantly more patients in the PU group received adjuvant chemotherapy than the RNU arm, respectively (n=21, 25.9% vs. n=127, 16.8%, p=0.05).
Our results, and congruent outcomes from other investigators, support PU as an attractive therapeutic option in selected patients with UTUC. Data emphasizing the increased incidence of chronic kidney disease, osteoporosis, proteinuria, and anemia after radical nephrectomy vs partial nephrecromy surgery in the setting of renal carcinoma may be extrapolated to patients with UTUC . Renal preservation is especially critical for advanced stage tumors where adjuvant or salvage systemic chemotherapy may be required and loss of glomerular reserves with RNU may preclude the use of optimal platinum-based chemotherapy regimens. In fact, we discovered adjuvant chemotherapy was administered to a significantly higher proportion of patients that underwent PU versus RNU (25.9% vs. 16.8%, p=0.05), despite a higher proportion of advanced stage disease in the RNU group. Our study supports the existing data that PU and RNU have equivalent long-term oncologic outcomes. A close look at the incidence of ureteral tumors (40%) and the utilization of PU (10%) suggests that PU may be underutilized. Renal preservation with PU may increase the probability of receiving effective adjuvant or salvage systemic therapy after surgery while minimizing adverse outcomes associated with glomerular loss.
Aditya Bagrodia, MD and Vitaly Margulis, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX
Vitaly Margulis, MD
UT Southwestern Medical Center at Dallas
Department of Urology
5323 Harry Hines Blvd. J8.130
Dallas, Texas 75390-9110