Published online Nov 6, 2020. doi: 10.12998/wjcc.v8.i21.5104
Peer-review started: May 15, 2020
First decision: September 12, 2020
Revised: September 14, 2020
Accepted: September 23, 2020
Article in press: September 23, 2020
Published online: November 6, 2020
Upper urinary tract urothelial carcinomas (UTUC) is a relatively uncommon disease accounting for only 5%-10% of all urothelial carcinomas. The current standard surgical treatment is radical nephroureterectomy (RNU) with bladder cuff excision (BCE), which consists of two separate procedures, i.e. the removal of the ipsilateral distal ureter and partial cystectomy along with the ureteral orifice. Guidelines purport that laparoscopic RNU has equivalent oncological efficacy compared to open RNU when adhering to strict oncological principles. Although, the safety and efficacy of the second step involved in the BCE method, has been debated by urologists for a number of years.
There is currently no consensus about which management technique is superior for treating primary UTUC. We previously found that intrasvesical incision of the bladder cuff (IVBC) is more strongly associated with improved intravesical recurrence-free survival, compared to EVBC and TUBC. Although, the findings can be criticized because pooled analysis did not adjust for other important clinic-opathological parameters, such as tumor multiplicity, location, stage, grade, gender.
To retrospectively collate data from a nationwide tertiary care center in mainland China, in order to investigate the oncological impact of the three, different BCE techniques on primary UTUC patients following RNU across this Asian population.
Data from 248 primary UTUC patients who underwent RNU with BCE between January 2004 to December 2018 were retrospectively analyzed. Patients were analyzed according to each BCE methods. Data extracted included patient demographics, perioperative parameters and oncological outcomes. Statistical analyses were performed using chi-square and log-rank tests. The Cox proportional hazards regression model was utilized to identify independent predictors. P < 0.05 was considered statistically significant.
Of the 248 participants, 39.9% (n = 99) underwent IVBC, 38.7% (n = 96) EVBC, and 21.4% (n = 53) TUBC. At a median follow-up of 44.2 mo, bladder recurrence developed in 17.2%, 12.5%, and 13.2% of the cases, respectively. Cancer specific deaths occurred in 11.1%, 5.2%, and 7.5%, respectively. Kaplan-Meier survival curves with a log-rank test highlighted no significant differences in intravesical recurrence-free survival, cancer-specific survival, and overall survival among these approaches with P values of 0.987, 0.825 and 0.497, respectively. Under multivariate analysis, the lower ureter location appears to have inferior intravesical recurrence-free survival (P = 0.042). However, cancer-specific survival and overall survival were independently influenced by tumor stage (HR: 8.439; 95%CI: 2.424-29.377; P = 0.001) and lymph node status (HR: 14.343; 95%CI: 5.176-39.745; P < 0.001).
EVBC and TUBC appear to have equivalent oncologic outcomes to IVBC for treating UTUC when adhering to strict oncological principles, although these methods have the advantage of being minimally invasive. Selecting which of these methods to implement is dependent upon a surgeon’s experience, patient’s individual characteristics and imparting best evidence to inform patient choices.
This study adds to the evidence-base and will support urologists; however, larger, rigorously designed, multicenter studies with long-term outcomes are still required.