Kidney-sparing surgery (KSS) and radical nephroureterecttomy (RNU) lead to similar survival for low-grade and noninvasive upper tract urothelial carcinoma (UTUC), according to a review published in European Urology.
Though uncommon, management of UTUC poses unique challenges for practicing oncologists. For years, the standard of care was only RNU with bladder-cuff removal in those with localized disease. However, recent advances in diagnostic imaging and endoscopic armamentarium have markedly enhanced the role of KSS for patients with UTUC characterized by low-risk features. Still, evidence regarding the use of KSS versus RNU in patients with different UTUC stage has been limited.
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Therefore, researchers led by Thomas Seisen, Pitie´-Salpe´trie`re Hospital (Paris, France), conducted a comprehensive review of published studies comparing oncologic outcomes of KSS versus RNU in patients with UTUC in the hopes of improving the quality of recommendations issued by the European Association of Urology Non-muscle Invasive Bladder Cancer Guidelines.
For the review, a computerized bibliographic search of Medline, Embase, and Cochrane databases was performed for all studies comparing oncologic outcomes of KSS versus RNU. A total of 22 articles published between 1999 and 2015 were deemed eligible for study inclusion. The primary outcome was cancer-specific survival, with secondary endpoints of overall survival, local recurrence-free survival, bladder recurrence-free survival, metastases recurrence-free survival, and rates of salvage in RNU and KSS arms.
Overall, researchers found no significant difference between KSS and RNU groups in terms of 5-year, 10-year, or last follow-up cancer-specific survival. However, it was found in one study that patients treated with KSS for grade 2 disease were more likely to experience cancer-specific death. Additionally, shorter 5- and 10-year overall survival was observed among patients with stage 3 disease when treated with KSS. Metastasis recurrence-free survival was similar in both treatment groups, although there was some risk of developing metastases after KSS, even for patients with low-grade disease.
“To the best of our knowledge, this study represents the most robust and extensive literature review of the comparative oncologic effectiveness of KSS versus RNU for UTUC,” authors of the study wrote. “[O]ur selected studies showed that patients [with early-stage UTUC] treated with KSS had similar [cancer-specific survival] with greater [overall survival] when compared with those treated with RNU after attempting to adjust correctly for all relevant adverse baseline characteristics between treatment groups in multivariate analysis.”
Researchers concluded that, despite being limited by the low quality of available retrospective studies and selection bias, their findings suggest similar survival after KSS versus RNU but only for low-grade and noninvasive UTUC. Future research should focus on controlling for potential selection bias between treatment groups. —Sean McGuire
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