A Systematic Review and Meta-analysis of Clinicopathologic Factors Linked to Intravesical Recurrence After Radical Nephroureterectomy to Treat Upper Tract Urothelial Carcinoma

Abstract

Context: There is an ongoing debate about the factors that influence intravesical recurrence (IVR) after radical nephrouretectomy (RNU) to treat upper tract urothelial carcinoma (UTUC).

Objective: To assess significant predictors of IVR after RNU from a systematic review of the literature and meta-analysis.

Evidence acquisition: A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all reports that included detailed results of multivariate analyses on the predictors of IVR. According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, we selected 18 retrospective studies that each included more than 100 patients treated exclusively with RNU between 2007 and 2014. Cumulative analyses of available hazard ratios (HRs) and their corresponding 95% confidence intervals were conducted using R software to assess the potential predictors of IVR.

Evidence synthesis: Among the 8275 patients included, 2402 (29%) were diagnosed with IVR within a median time of 22.2 mo (range 6.7-56.5). Patient-specific predictors were as follows: male gender (HR 1.37; p<0.001), previous bladder cancer (HR 1.96; p<0.001), and preoperative chronic kidney disease (HR 1.87; p=0.002). Tumor-specific predictors were as follows: positive preoperative urinary cytology (HR 1.56; p<0.001), ureteral location (HR 1.27; p<0.001), multifocality (HR 1.61; p=0.002), invasive pT stage (HR 1.38; p<0.001), and necrosis (HR 2.17; p=0.02). Treatment-specific predictors were as follows: a laparoscopic approach (HR 1.62; p=0.003), extravesical bladder cuff removal (HR 1.22; p=0.02), and positive surgical margins (HR 1.90; p=0.004).

Conclusions: A meta-analysis of available data identified significant predictors of IVR that should be systematically assessed to propose a risk-adapted approach to adjuvant intravesical instillation of chemotherapy and cystoscopic surveillance after RNU.

Patient summary: In this report, we looked at the factors linked to intravesical recurrence after radical nephroureterectomy to treat upper urinary tract urothelial carcinoma. We identified patient-, tumor- and treatment-specific characteristics that should be systematically assessed to guide postoperative decision-making.

Keywords: Bladder neoplasm; Prognostic; Recurrence; Renal pelvis; Survival; Ureter; Urinary tract; Urothelial carcinoma.