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BJUI Compass May 2023Upper tract urothelial carcinoma (UTUC) is the malignant transformation of urothelial cells, from the renal calyces to the ureteral orifices. While the benefits of... (Review)
Review
BACKGROUND
Upper tract urothelial carcinoma (UTUC) is the malignant transformation of urothelial cells, from the renal calyces to the ureteral orifices. While the benefits of minimally invasive nephroureterectomy over their open counterpart have been established, the optimal technique remains a debate. We aimed to assess current evidence in the literature and compare outcomes between robotic-assisted (RANU) and laparoscopic nephroureterectomy (LNU).
METHODS
A systematic review of the literature was performed for studies comparing RANU and LNU for bladder cancer. Outcome measurements were recurrence rates (local and distal), positive margins, positive lymph node yield and perioperative outcomes. Meta-analysis was performed using .
RESULTS
Our results demonstrate a significantly higher mortality rate in patients undergoing laparoscopic nephroureterectomy when compared with the robotic-assisted approach for the treatment of UTUC (1.8% vs. 1.1%, = 0.008); however, these results were inconsistent on sensitivity analysis and should therefore be interpreted with caution. No significant difference was observed for other outcomes.
CONCLUSION
The ideal approach to minimally invasive radical nephroureterectomy remains undetermined. Future research, ideally prospective randomised studies, should focus on long-term outcomes, in particular recurrence, recurrence-free survival, overall survival and the correlation between surgical technique and survival.
PubMed: 37025468
DOI: 10.1002/bco2.208 -
Therapeutic Advances in Urology 2023Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial... (Review)
Review
INTRODUCTION
Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone.
METHODS
For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts.
RESULTS
For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock.
CONCLUSION
A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.
PubMed: 37188157
DOI: 10.1177/17562872231171757 -
European Journal of Surgical Oncology :... Nov 2016To perform a systematic review and meta-analysis of the comparative studies reporting oncological and renal function outcomes of segmental ureterectomy (SU) versus... (Comparative Study)
Comparative Study Meta-Analysis Review
A systematic review and meta-analysis of oncological and renal function outcomes obtained after segmental ureterectomy versus radical nephroureterectomy for upper tract urothelial carcinoma.
OBJECTIVE
To perform a systematic review and meta-analysis of the comparative studies reporting oncological and renal function outcomes of segmental ureterectomy (SU) versus radical nephroureterectomy (RNU) for upper tract urothelial carcinomas (UTUC).
MATERIALS AND METHODS
A literature search on Pubmed, Embase, and the Cochrane library was conducted according to the PRISMA guidelines, and a meta-analysis was performed to assess cancer-specific survival (CSS), overall survival (OS), recurrence-free survival (RFS), intravesical recurrence free survival (IVRFS) and surgery-related variations in estimated glomerular filtration rate (eGFR).
RESULTS
A total of 11 retrospective studies with 3963 patients who underwent either SU (n = 983; 24.8%) or RNU (n = 2980; 75.2%) were included. Although patients treated with SU were more likely to be diagnosed with favorable pathological features, the meta-analysis of unadjusted data revealed no significant difference between both groups in terms of CSS (HR 0.90, p = 0.33) and OS (HR 0.98, p = 0.93). Accordingly, the meta-analysis of adjusted data confirmed equivalent CSS (HR = 0.90, p = 0.47) between SU and RNU. Similarly, no significant difference was found in terms of RFS (HR 1.06, p = 0.72) and IVRFS (HR 1.35, p = 0.39). However, a significant decreased risk of impaired renal function was observed after SU when compared to RNU (mean eGFR difference = 9.32 ml/1.73 m, p = 0.007).
CONCLUSION
Although adverse patient and tumor characteristics were not equally balanced between treatment arms, our systematic review and meta-analysis supports similar oncological outcomes between SU and RNU, with better preservation of renal function after SU. As such, SU should be preferably used as the first-line treatment for low-risk ureter tumors, while considered for selected cases of high-risk disease.
Topics: Carcinoma, Transitional Cell; Glomerular Filtration Rate; Humans; Kidney Neoplasms; Nephrectomy; Treatment Outcome; Ureter; Ureteral Neoplasms
PubMed: 27612412
DOI: 10.1016/j.ejso.2016.08.008 -
Cancers Oct 2022Neoadjuvant chemotherapy is a well-established concept in muscle-invasive bladder cancer with known advantages in overall survival. Phase II trials show encouraging... (Review)
Review
Neoadjuvant chemotherapy is a well-established concept in muscle-invasive bladder cancer with known advantages in overall survival. Phase II trials show encouraging response rates for neoadjuvant immunotherapy before radical surgery in urothelial cancer. There is no recommendation for neoadjuvant therapy in upper tract urothelial carcinoma before nephroureterectomy. Our aim was to assess the available data on neoadjuvant chemotherapy and immunotherapy before nephroureterectomy in patients with high-risk upper tract urothelial carcinoma in terms of pathological downstaging and oncological outcomes. Two investigators screened PubMed/Medline for comparative trials in the English language. We identified 368 studies and included eleven investigations in a systematic review and meta-analysis for neoadjuvant chemotherapy and control groups. There were no comparative trials investigating immunotherapy in this setting. All 11 studies reported on overall pathological downstaging with a significant effect in favor of neoadjuvant chemotherapy (OR 5.17; 95%CI 3.82; 7.00). Pathological complete response and non-muscle invasive disease were significantly higher in patients receiving neoadjuvant chemotherapy (OR 12.07; 95%CI 4.16; 35.03 and OR 1.62; 95%CI 1.05; 2.49). Overall survival and progression-free survival data analysis showed a slight benefit for neoadjuvant chemotherapy. Our results show that neoadjuvant chemotherapy is effective in downstaging in upper urinary tract urothelial carcinoma. The selection of patients and chemotherapy regimens are unclear.
PubMed: 36230764
DOI: 10.3390/cancers14194841 -
Current Oncology (Toronto, Ont.) Dec 2022Upper tract urothelial carcinoma (UTUC) is a rare form of malignancy comprising only 5% of urothelial cancers. The mainstay of treatment is radical nephroureterectomy... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Upper tract urothelial carcinoma (UTUC) is a rare form of malignancy comprising only 5% of urothelial cancers. The mainstay of treatment is radical nephroureterectomy (RNU) with bladder cuff excision. Neoadjuvant or adjuvant chemotherapy is often used in locally advanced disease. The role of adjuvant radiotherapy (RT), however, remains controversial. To further explore the potential role of adjuvant RT, we performed a systematic review and meta-analysis of the literature from 1990 to present.
METHODS AND MATERIALS
We identified 810 candidate articles from database searches, of which 67 studies underwent full-text review, with final inclusion of 20 eligible studies. Among the included studies, there were no randomized controlled trials and a single prospective trial, with the remainder being retrospective series. We performed quantitative synthesis of the results by calculating the pooled odds ratios (OR) for the primary outcome of locoregional recurrence (LRR) and secondary outcomes of overall survival (OS), cancer-specific survival (CSS) and distant recurrence (DR).
RESULTS
Adjuvant RT, which was mostly prescribed for locally advanced or margin-positive disease following RNU, significantly reduced locoregional recurrence risk OR 0.43 (95% CI: 0.23-0.70), and the effect remained significant even following subgroup analysis to account for adjuvant systemic therapy. The effect of adjuvant RT on 3-year OS, 5-year CSS and DR was non-significant. However, 5-year OS was unfavourable in the adjuvant RT arm, but study heterogeneity was high, and analysis of small-study effects and subgroups suggested bias in reporting of outcomes.
CONCLUSIONS
Adjuvant RT in the setting of locally advanced UTUC improves locoregional control following definitive surgery, but does not appear to improve OS. Higher-quality studies, ideally randomized controlled trials, are needed to further quantify its benefit in this setting, and to explore multi-modal treatments that include systemic agents given concomitantly or sequentially with RT, which may offer an OS benefit in addition to the locoregional control benefit of RT.
Topics: Humans; Carcinoma, Transitional Cell; Urinary Bladder Neoplasms; Radiotherapy, Adjuvant; Retrospective Studies; Prospective Studies; Neoplasm Recurrence, Local
PubMed: 36661651
DOI: 10.3390/curroncol30010002 -
Medicine Jun 2023This systematic review and meta-analysis aim to evaluate the efficacy and safety of completely retroperitoneoscopic nephroureterectomy (CRNU) for the treatment of upper... (Meta-Analysis)
Meta-Analysis
Systematic review and meta-analysis of completely retroperitoneoscopic nephroureterectomy versus traditional retroperitoneoscopic nephroureterectomy in upper tract urothelial carcinoma.
BACKGROUND
This systematic review and meta-analysis aim to evaluate the efficacy and safety of completely retroperitoneoscopic nephroureterectomy (CRNU) for the treatment of upper urinary tract urothelial carcinoma (UTUC).
METHODS
A systematic review of PubMed and Web of Science databases was conducted to identify trials comparing the outcomes of CRNU and other surgical procedures. A total of 6 case-control studies were selected for analysis. The efficacy and safety of CRNU were evaluated using mean difference or hazard ratio (HR) with 95% CIs, employing continuous or dichotomous method with a random or fixed-effect model. Meta-analysis was performed using STATA 11.0 software.
RESULTS
The meta-analysis indicated that CRNU in subjects with UTUC was significantly associated with a shorter operation time (standardized mean difference, -1.36; 95% CI, -1.61 to -1.11, P < .001) and lower blood loss (standardized mean difference, -0.54; 95% CI, -0.77 to -0.31, P < .001) when compared to traditionally retroperitoneoscopic nephroureterectomy (TRNU). No significant difference was observed in the occurrence of grade I & II complications (HR, 1.04; 95% CI, 0.49-2.2, P = .915) and total complications (HR, 0.69; 95% CI, 0.38-1.27, P = .238) between CRNU and TRNU.
CONCLUSION
The findings suggest that CRNU is an advanced surgical technique that is safe and effective for the treatment of UTUC. We recommend that CRNU be further employed for patients with UTUC. Further randomized, multicenter trials are needed to validate these results, given the limitations of this study.
Topics: Humans; Carcinoma, Transitional Cell; Urinary Bladder Neoplasms; Nephroureterectomy; Case-Control Studies; Databases, Factual; Retrospective Studies
PubMed: 37352043
DOI: 10.1097/MD.0000000000034112 -
Asian Pacific Journal of Cancer... 2015To evaluate and update evidence for prognostic effects of kidney-sparing (KS) management and nephroureterectomy (NU) for upper tract urothelial carcinomas. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate and update evidence for prognostic effects of kidney-sparing (KS) management and nephroureterectomy (NU) for upper tract urothelial carcinomas.
MATERIALS AND METHODS
Pubmed, Embase and the Cochrane Library were retrieved for the identification of comparative studies of kidney-sparing procedure and nephroureterectomy for upper tract urothelial carcinoma prior to December 2014. The data were extracted independently by 2 reviewers and the quality of the included studies was assessed. Review Manager 5.3 and STATA 13 were used to perform the meta-analysis.
RESULTS
Twenty-three observational studies including 1,587 KS and 3,996 NU were evaluated. The results of the meta-analysis showed that nephroureterectomy had no significant benefit with regard to intravesical recurrence (IRFS), metastasis (MFS), cancer specific survival (CSS) and overall survival (OS) except the total tumor recurrence (RFS) when compared with kidney sparing management. The respectively pooled outcomes were HR 1.36 (0.69-2.68, P=0.38) for IRFS, 1.09 (0.59-2.01, P=0.78) for MFS, 1.17 (0.77-1.79, P=0.47) for CSS, 1.50 (0.90-2.48, P=0.12) for OS and 1.61 (1.03-2.51, P=0.04) for RFS.
CONCLUSIONS
On the whole, kidney-sparing management had equivalent prognostic effect on upper tract urothelial carcinoma as the standard nephroureterectomy except in tumor recurrence. However, the results should be interpreted with caution for lack of stage and grade stratification and multi-center randomized controlled trials are still needed to verify our results.
Topics: Disease Management; Humans; Kidney Neoplasms; Nephrectomy; Organ Sparing Treatments; Prognosis; Ureter; Ureteral Neoplasms
PubMed: 26320471
DOI: 10.7314/apjcp.2015.16.14.5907 -
Medicine Aug 2018To evaluate the efficacy and safety of laparoscopic nephroureterectomy (LNU) and open nephroureterectomy (ONU) for the treatment of upper urinary tract urothelial... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate the efficacy and safety of laparoscopic nephroureterectomy (LNU) and open nephroureterectomy (ONU) for the treatment of upper urinary tract urothelial carcinoma (UTUC).
METHODS
PubMed, Embase, and Cochrane databases were selected for systematic review of trials that compared outcomes of LNU and ONU. Meta-analysis was performed using RevMan 5.3 and STATA 13.0 software.
RESULTS
LNU was associated with longer operation time (P < .001), shorter hospital stay (P < .001), less blood loss (P = .006) and lower rate of transfusion (P < .001). The occurrence of complications, including minor (P = .52), major (P = .21) and total complications (P = .19) were similar between LNU and ONU. There was no significant difference in the rate of 5-year recurrence-free survival (P = .90), 5-year cancer-specific survival (P = .12), and 5-year overall survival (P = .11) as well as 2-year RFS (P = .84), 2-year CSS (P = .86), and 2-year OS (P = .25).
CONCLUSION
Our results indicated that LNU is a safe and effective method to treat UTUC. Given the limitations of this study, further multicenter, randomized trials are required to confirm these findings.
Topics: Adult; Aged; Aged, 80 and over; Carcinoma; Disease-Free Survival; Female; Humans; Laparoscopy; Length of Stay; Male; Middle Aged; Nephroureterectomy; Operative Time; Treatment Outcome; Urologic Neoplasms; Urothelium
PubMed: 30170392
DOI: 10.1097/MD.0000000000011954 -
European Urology Focus Mar 2023We systematically reviewed the literature and summarized oncologic and safety outcomes for endoscopic management (EM) compared to radical nephroureterectomy (RNU) for... (Meta-Analysis)
Meta-Analysis Review
Oncologic and Safety Outcomes for Endoscopic Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An Updated Systematic Review and Meta-analysis.
We systematically reviewed the literature and summarized oncologic and safety outcomes for endoscopic management (EM) compared to radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC). Studies comparing oncologic and/or safety results for EM versus RNU in patients with UTUC were included in our review. Overall, 13 studies met the criteria, and five studies were included in a meta-analysis using adjusted hazard ratios (HRs) for overall survival (OS), cancer-specific survival (CSS), and bladder recurrence-free survival (BRFS). EM was associated similar OS (HR 1.27, 95% confidence interval [CI] 0.75-2.16), CSS (HR 1.37, 95% CI 0.99-1.91), and BRFS (HR 0.98, 95% CI 0.61-1.55) to RNU, while 28-85% of patients treated with EM experienced upper tract recurrence across the studies. EM required more interventions with a higher cumulative risk of complications and lower likelihood of renal preservation. In summary, EM for low-grade UTUC had comparable survival outcomes to RNU at the cost of higher local recurrence rates resulting in a need for long-term rigorous surveillance and repeated interventions. PATIENT SUMMARY: For selected cases of cancer in the upper urinary tract, surgical treatment via a telescope inserted through the urethra or the skin (endoscope) results in cancer control outcomes that are comparable to those after removal of the kidney and ureter. However, because of its higher rate of local recurrence, this approach requires repeated endoscopic treatment sessions. Patients should be well informed about these issues to help in shared decision-making.
Topics: Humans; Nephroureterectomy; Urinary Bladder Neoplasms; Carcinoma, Transitional Cell; Ureter; Ureteroscopy
PubMed: 36463089
DOI: 10.1016/j.euf.2022.11.016 -
Minerva Urologica E Nefrologica = the... Jun 2018Conservative management of upper tract urothelial cancer (UTUC) is becoming increasingly popular: the key to success is correct selection of patients with low-risk UTUC... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Conservative management of upper tract urothelial cancer (UTUC) is becoming increasingly popular: the key to success is correct selection of patients with low-risk UTUC based on size (≤2 cm), focality (single lesion), stage (< T2), and grade (low grade). Despite the recent growing interest in the conservative approach to UTUC, the diagnostic process is still a challenge, and kidney-sparing surgery (KSS) is traditionally reserved for patients with contraindications to radical nephroureterectomy. In order to explore the "state of the art" in the diagnosis and conservative treatment of UTUC, a systematic review of the literature was performed.
EVIDENCE ACQUISITION
A PubMed, Scopus, and Cochrane search for peer-reviewed studies was performed using the keywords "upper tract urothelial carcinoma" OR "UTUC" OR "upper urinary tract" AND "biopsy" OR "diagnosis" OR "endomicroscopy" OR "imaging" AND "URS" OR "ureteroscopy" OR "kidney-sparing surgery" OR "laser ablation" OR "ureterectomy". We considered as relevant comparative prospective studies (randomized, quasi-randomized, no randomized), retrospective studies, meta-analyses, systematic reviews, and case report series written in the English language. Letters to the editor and contributions written in languages other than English were not considered of value for this review. Eligible articles were reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria.
EVIDENCE SYNTHESIS
Two hundred and sixty-three (263) records were identified using the above-mentioned keywords. Overall, 30 studies were considered relevant for the purpose of this systematic review and for the evidence evaluation process during qualitative synthesis. The outcomes evaluated in this review were the current diagnostic methods and the KSS approaches in UTUC. Furthermore, we included in the review the emerging technology for distinguishing between normal tissue, low-grade UTUC, and high-grade UTUC.
CONCLUSIONS
Conclusive diagnosis is fundamental to the decision-making process in patients who could benefit from conservative treatment of UTUC. The most relevant diagnostic modalities are computed tomography urography, local urine cytology, and ureteroscopy with acquisition of an adequate biopsy sample for histology. KSS includes the endourological approach and segmental ureterectomy. Promising technology in the endourological management of UTUC helps in providing intraoperative information on UTUC grading and staging, with a high accuracy. Patients treated conservatively have to undergo stringent postoperative follow-up in order to detect and, if necessary, treat any recurrence promptly. Further larger and multicenter studies are needed to confirm these findings.
Topics: Conservative Treatment; Humans; Kidney; Nephroureterectomy; Urologic Neoplasms; Urologic Surgical Procedures
PubMed: 29392926
DOI: 10.23736/S0393-2249.18.03058-8