Survival and Long-term Effects of Kidney-sparing Surgery Versus Radical Nephroureterectomy on Kidney Function in Patients with Upper Urinary Tract Urothelial Carcinoma

Abstract

Background: Current European Association of Urology (EAU) guidelines discriminate between high- and low-risk upper urinary tract urothelial carcinoma (UTUC) to determine treatment by means of radical nephroureterectomy (RNU) or kidney-sparing surgery (KSS).

Objective: To compare long-term oncological outcomes and renal function for patients with UTUC treated by RNU versus KSS.

Design setting and participants: A retrospective cohort study, including 186 renal units with nonmetastatic UTUC treated in a tertiary referral centre between 2010 and 2021, was conducted.

Intervention: RNU, ureterorenoscopy, percutaneous tumour resection, and segmental ureteral resection.

Outcome measurements and statistical analysis: Recurrence-free survival, metastasis-free survival (MFS), overall survival (OS), cancer-specific survival (CSS), and renal function were analysed by means of the log-rank test and the independent-sample t test.

Results and limitations: OS was 71.1% for the RNU group and 81.9% for the KSS group. In a cohort matched for propensity weight based on EAU risk stratification progression-free survival (PFS; RNU 96.0%; KSS 86.0%), MFS (RNU 72.0%; KSS 84.0%), CSS (RNU 84.0%; KSS 86.0%), and OS (RNU 76.0%; KSS 76.0%) were all similar between both groups. No significant differences in renal function were seen at 2 and 5 yr after the intervention. Although this series represents the largest cohort of (high-risk) UTUC patients treated by means of KSS to date, it is not suitable for performing a multivariate analysis.

Conclusions: PFS, MFS, CSS, and OS were all comparable when analysing the RNU and KSS groups. Similar results for groups with evenly distributed risk factors and a large percentage of high-risk disease suggest that current risk stratification might not be accurate in discriminating low-risk from high-risk disease.

Patient summary: In this report, we looked at outcomes for upper urinary tract urothelial carcinoma in a specialised hospital. We conclude that kidney-sparing surgery and radical nephroureterectomy have comparable outcomes and that risk factors for worse outcome might not be identified correctly.

Keywords: Kidney-sparing surgery; Radical nephroureterectomy; Upper urinary tract urothelial carcinoma.

Fig. 1

Survival for RNU and KSS. Numbers at risk after 11 yr are as follows: intravesical recurrence—number at risk RNU 49.7 and number at risk KSS 46.5; ipsilateral recurrence—number at risk RNU 88.3 and number at risk KSS 8.5; progression—number at risk RNU 93.5 and number at risk KSS 74.0; metastasis—number at risk RNU 48.1 and number at risk KSS 84.2; cancer specific—number at risk RNU 59.5 and number at risk KSS 74.1; and overall—number at risk RNU 51.5 and number at risk KSS 67.7. KSS = kidney-sparing surgery; RNU = radical nephroureterectomy.

Fig. 2

Survival in a cohort matched for propensity weight based on EAU risk stratification. Numbers at risk after 11 yr are as follows: intravesical recurrence-free survival—log rank p = 0.029, number at risk RNU 62.7, and number at risk KSS 54.6; ipsilateral recurrence-free survival—log rank p < 0.0001, number at risk RNU 82.2, and number at risk KSS 24.4; progression-free survival—log rank p = 0.147, number at risk RNU 92.7, and number at risk KSS 79.7; metastasis-free survival—log rank p = 0.217, number at risk RNU 47.6, and number at risk KSS 79.7; cancer-specific survival—log rank p = 0.490, number at risk RNU 69.1, and number at risk KSS 76.2; and overall survival—log rank p = 0.691, number at risk RNU 60.6, and number at risk KSS 61.4. KSS = kidney-sparing surgery; RNU = radical nephroureterectomy.

Fig. 3

Renal function for patients treated with RNU or KSS over time. eGFR = estimated glomerular filtration rate; KSS = kidney-sparing surgery; RNU = radical nephroureterectomy.