Original article
Multi-institutional analysis of renal function outcomes following radical nephroureterectomy and partial ureterectomy for upper tract urothelial carcinoma

https://doi.org/10.1016/j.urolonc.2015.03.006Get rights and content

Abstract

Purpose

To compare renal function outcomes in patients undergoing radical nephroureterectomy (RNU) or partial (distal) ureterectomy (PU) for upper tract urothelial carcinoma (UTUC).

Methods

Clinicopathologic data of patients undergoing RNU or PU for UTUC from 1998 to 2012 were compiled. Glomerular filtration rate was calculated preoperatively and postoperatively using the Modification of Diet in Renal Disease equation. We defined “event” as new-onset stage III chronic kidney disease (CKD) or worsening of CKD stage with preexisting CKD. Event-free survival was assessed with Kaplan-Meier methods. Cox regression analyses were performed to identify predictors of events.

Results

In total, 193 patients underwent RNU (n = 143) or PU (n = 50) over a median follow-up of 25.9 months. Overall, 15% of patients died of UTUC. High tumor grade (85.9% vs. 66.0%, P = 0.003) and locally advanced stage (>pT2, 37.8% vs. 18.0%, P = 0.014) were significantly more frequent in the RNU cohort. Stage III or higher CKD was present in 61% of RNU patients vs. 48% of PU patients (P = 0.135) at baseline. Although total event rate was higher in the PU cohort (66% vs. 43.4%, P = 0.008), event rates within the first 3 months of surgery were similar between the groups (P = 0.572). Adjuvant chemotherapy was the only predictor of events on Cox regression.

Conclusions

Rates of new-onset CKD or worsening of CKD stage were similar in patients treated with RNU and PU. Adjuvant chemotherapy may have a more significant effect on renal outcomes than surgical approach, warranting further investigation. Consideration should be given to preoperative chemotherapy, as adjuvant chemotherapy is limited by decreased renal function following surgery.

Introduction

Upper tract urothelial carcinomas (UTUC) are uncommon, comprising approximately 5% of urothelial tumors [1], [2]. Radical nephroureterectomy (RNU) with removal of the distal ureter and bladder cuff is currently the referent gold standard treatment of UTUC [3], [4], [5], [6]. However, RNU has been shown to be an independent risk factor in the development of stage III chronic kidney disease (CKD) when compared with nephron-sparing techniques [7], [8], [9] and can amount to a significant decline in estimated glomerular filtration rate (eGFR) [10], [11], thereby decreasing eligibility for platinum-based chemotherapy [12], [13], [14].

Nephron-sparing strategies, such as partial ureterectomy (PU), may be an attractive alternative to RNU in appropriately selected patients. Studies have demonstrated comparable long-term mortality in PU and RNU, with similar oncologic control in advanced stage disease [3], [15], [16], [17]. In perhaps the largest series to date of an international, contemporary, multi-institutional comparison of RNU and PU for UTUC, Bagrodia et al. [18] demonstrated equivalent long-term oncologic efficacy between the 2. PU conceivably offers the advantage of maximizing global renal function in selected patients and may thereby increase eligibility for adjuvant or salvage chemotherapy, while minimizing adverse outcomes associated with nephron loss. In the present study, we compare baseline and postoperative renal functional outcomes between RNU and PU in a multi-institutional contemporary cohort of patients with UTUC.

Section snippets

Materials and methods

Following institutional review board approval, a multi-institutional retrospective database was created containing clinicopathologic data of all patients undergoing RNU or PU for UTUC between 1998 and 2012 at the University of Texas Southwestern Medical Center (Dallas, TX) and the University of California San Diego (San Diego, CA). Patient demographics, comorbidities, and disease properties including tumor location, multifocality, pathologic stage, grade, concomitant carcinoma in situ, presence

Results

Clinicopathologic characteristics of our cohort are summarized in Table 1. In total, 193 patients were included, of whom 143 (74.1%) underwent RNU and 50 (25.9%) underwent PU. Median follow-up duration was 25.9 months (range: 1−150 months) following surgery, with a significantly longer median follow-up in the PU group (22.4 months [interquartile range {IQR}: 6.4−42.1] vs. 43.9 months [IQR: 18.8−82.1], P = 0.001). Median age was 69 years, and most were men (69.4%). In comparing the RNU and PU

Discussion

With the growing role for nephron-sparing approaches in the treatment of UTUC, we sought to compare renal function outcomes between RNU and PU in a multi-institutional contemporary cohort of patients with UTUC. Conceivably, the effect of surgical approach on renal function may affect eligibility for and appropriate timing of systemic chemotherapy administration in those who would derive benefit. We found that across all time points, though the difference did not achieve statistical

Conclusions

We conclude that operation type does not appear to be significantly associated with new-onset stage III CKD or worsening of CKD stage within the first 3 months following surgery for UTUC within our cohort. Patients undergoing RNU tend to have worse tumor characteristics and baseline renal function than PU patients. Meanwhile, the higher rate of adjuvant chemotherapy in the PU arm likely explains the lack of improvement in eGFR within that group. These results must be interpreted with the

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