Long-term endoscopic management of upper tract urothelial carcinoma: 20-year single-centre experience

Study Type Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Endoscopic management of small, low-grade, non-invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long-term survival outcomes of endoscopically-managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow-up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease-specific survival outcomes. The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long-term follow-up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade-stratified analysis of different outcomes, including upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and disease-specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low-grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres. OBJECTIVE To report the long-term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20-year period. PATIENTS AND METHODS Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment. Outcomes were obtained via retrospective analysis of notes, electronic records and registry data. Survival outcomes, including overall survival (OS), UTUC-specific survival (disease-specific survival; DSS), upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and progression-free survival, were estimated using KaplanMeier methods and grade-stratified differences were analyzed using the log-rank test. RESULTS Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years. All patients underwent ureteroscopy and biopsy-confirmation of pathology was obtained in 81% (n= 59) of the patients. In total, 14% (n= 10) of the patients underwent percutaneous resection. Median (range; mean) follow-up was 54 (1223; 62.8) months. Upper tract recurrence occurred in 68% (n= 50). Eventually, 19% (n= 14) of the patients proceeded to nephroureterectomy. The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months. CONCLUSIONS The present study represents one of the largest reported series of endoscopically-managed UTUC, with high pathological verification and long-term follow-up. Upper-tract recurrence is common, which mandates regular ureteroscopic surveillance. However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.