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. 2022 Jul 1:12:907975.
doi: 10.3389/fonc.2022.907975. eCollection 2022.

A Systematic Review and Meta-Analysis of Prognostic Nomograms After UTUC Surgery

Maximilian Pallauf  1   2 , Frederik König  1   3 , David D'Andrea  1 , Ekaterina Laukhtina  1   4 , Hadi Mostafaei  1   5 , Reza Sari Motlagh  1   6 , Fahad Quhal  1   7 , Abdulmajeed Aydh  1   8 , Takafumi Yanagisawa  1   9 , Tatsushi Kawada  1   10 , Pawel Rajwa  1   11 , Lukas Lusuardi  2 , Francesco Soria  12 , Pierre I Karakiewicz  13 , Morgan Rouprêt  14 , Michael Rink  3 , Yair Lotan  15 , Vitaly Margulis  15 , Nirmish Singla  16 , Evanguelos Xylinas  17 , Shahrokh F Shariat  1   4   15   18   19   20   21 , Benjamin Pradere  1   22
Affiliations

A Systematic Review and Meta-Analysis of Prognostic Nomograms After UTUC Surgery

Maximilian Pallauf et al. Front Oncol. .

Abstract

Background: Current guidelines recommend assessing the prognosis in high-risk upper tract urothelial carcinoma patients (UTUC) after surgery. However, no specific method is endorsed. Among the various prognostic models, nomograms represent an easy and accurate tool to predict the individual probability for a specific event. Therefore, identifying the best-suited nomogram for each setting seems of great interest to the patient and provider.

Objectives: To identify, summarize and compare postoperative UTUC nomograms predicting oncologic outcomes. To estimate the overall performance of the nomograms and identify the most reliable predictors. To create a reference tool for postoperative UTUC nomograms, physicians can use in clinical practice.

Design: A systematic review was conducted following the recommendations of Cochrane's Prognosis Methods Group. Medline and EMBASE databases were searched for studies published before December 2021. Nomograms were grouped according to outcome measurements, the purpose of use, and inclusion and exclusion criteria. Random-effects meta-analyses were performed to estimate nomogram group performance and predictor reliability. Reference tables summarizing the nomograms' important characteristics were created.

Results: The systematic review identified 26 nomograms. Only four were externally validated. Study heterogeneity was significant, and the overall Risk of Bias (RoB) was high. Nomogram groups predicting overall survival (OS), recurrence-free survival (RFS), and intravesical recurrence (IVR) had moderate discrimination accuracy (c-Index summary estimate with 95% confidence interval [95% CI] and prediction interval [PI] > 0.6). Nomogram groups predicting cancer-specific survival (CSS) had good discrimination accuracy (c-Index summary estimate with 95% CI and PI > 0.7). Advanced pathological tumor stage (≥ pT3) was the most reliable predictor of OS. Pathological tumor stage (≥ pT2), age, and lymphovascular invasion (LVI) were the most reliable predictors of CSS. LVI was the most reliable predictor of RFS.

Conclusions: Despite a moderate to good discrimination accuracy, severe heterogeneity discourages the uninformed use of postoperative prognostic UTUC nomograms. For nomograms to become of value in a generalizable population, future research must invest in external validation and assessment of clinical utility. Meanwhile, this systematic review serves as a reference tool for physicians choosing nomograms based on individual needs.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=282596, identifier PROSPERO [CRD42021282596].

Keywords: UTUC; nomograms; oncologic outcome; prognostic models; upper tract urothelial carcinoma.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer DE declared a shared affiliation with the author EL to the handling editor at the time of review.

Figures

Figure 1
Figure 1
This figure shows the PRISMA flow chart of the study selection process. From: Page et al. (18).
Figure 2
Figure 2
This figure shows the nomogram group stratification process. Further, it lists all nomograms within each group.
Figure 3
Figure 3
PROBAST summary (RoB domains and applicability domains) for all nomogram development (A, B) and validation studies (C, D) included in this systematic review.
Figure 4
Figure 4
Summary forest plot of c-Index meta-analyses: The forest plot lists the results of individual meta-analyses. For each meta-analysis, the nomogram group, the statistical approach, the number of values included (n), the prediction interval (lower limit – upper limit), and the c-Index summary estimate (estimate and 95% CIs) are given.
See this image and copyright information in PMC

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