Kidney-sparing surgery may be safe and effective in controlling upper tract urothelial carcinoma (UTUC) in patients who are followed closely, including those with high-risk disease, researchers reported at the AUA2021 Virtual Experience.

The gold standard treatment for UTUC is radical nephroureterectomy (RNU), Nora Hendriks, an MD/PhD candidate at the University of Amsterdam in Amsterdam, the Netherlands, and colleagues explained. Criteria to qualify for kidney-sparing surgery (KSS), however, have become less strict in consecutive guidelines, allowing more patients to opt for segmental ureter resection, ureterorenoscopy, or percutaneous tumor resection instead of RNU, she said.

In her team’s retrospective review of 180 patients with histopathologically confirmed nonmetastatic UTUC, metastasis-free survival, cancer-specific survival, and overall survival rates over approximately 125 months were all significantly higher for patients who were treated with KSS compared with RNU.

Even high-risk patients treated with KSS outside the scope of current European Association of Urology (EAU) guidelines had improved survival outcomes, Hendriks reported. In the study, 74.2% of the KSS group were considered high risk, compared with 93.8% of the RNU group. High-risk features were similarly distributed within both groups, including high-grade disease, invasive disease, tumor size larger than 2 cm, multifocality, hydronephrosis, cystectomy, and high-grade urothelial carcinoma of the bladder.

In an interview, Hendriks said, “This begs the question: Is current risk stratification based on clinical variables stated in EAU guidelines correctly discriminating between high-risk and low-risk disease?”

Among high-risk patients, the RNU group had significantly higher intravesical and ipsilateral recurrence-free survival. The differences in intravesical recurrence rate were likely partly influenced by a post-RNU regimen of intravesical mitomycin C, which started in 2017, she noted. The ipsilateral finding might reflect tumor seeding down the tract in the KSS group, Hendriks noted, or a longstanding tumor. In the KSS group, 84.3%, 10.1%, and 5.6% underwent ureterorenoscopy, segmental ureter resection, and percutaneous tumor resection, respectively.

Estimated glomerular filtration rate (in mL/min/1.73 m²) was comparable at baseline for both the RNU and KSS group (57.02 vs 53.52, respectively). There were no significant differences at 2 (51.18 vs 44.75) and 5 years (51.03 vs 45.29) after intervention.

As UTUC is a rare disease and EAU guidelines are still quite young and partly based on low-quality evidence, a health care team’s experience is essential for disease management and to attain favorable results from kidney-sparing procedures, Hendriks said. For safety, several surgeons need to consult on each individual case. After surgery, it is crucial to implement a stringent, clearly defined follow-up protocol including regular ureterorenoscopy, cystoscopy, and computed tomography-urography.

Reference

Hendriks N, Baard J, Beerlage HP, et al. Eleven years of experience with upper tract urothelial carcinoma: survival and renal function after kidney-sparing surgery versus radical nephroureterectomy. Presented at: AUA2021 Virtual Experience held September 10-13, 2021. PD64-10.