Segmental ureterectomy non-inferior to radical nephroureterectomy in high-risk UTUC

Following an increase of adoption among surgeons, segmental ureterectomy (SU) appeared to be non-inferior to radical nephroureterectomy (RNU) in treating patients with high-risk upper tract urothelial carcinoma (UTUC), according to findings presented at the 2021 Society of Urologic Oncology Annual Meeting.

“Radical nephroureterectomy is widely considered the gold standard for high-risk upper tract urothelial carcinoma. Segmental ureterectomy has had increased adoption for high-risk UTUC, particularly for distal ureteric tumors, but its oncological equivalence remains unclear,” Siv Venkat, MD, FRCS, urology fellow, Weill Cornell Medical College, said in a virtual presentation of the findings. “The purpose of this poster was to examine current trends in RNU and SU for upper tract disease, look at patient factors contributing to the performance of SU, look at the rates of lymph node dissection, and look at survival for RNU and SU in this high-risk disease population.”

The researchers utilized the National Cancer Database to identify 30,861 patients with nonmetastatic UTUC with urothelial histology who underwent extirpative surgery from 2004 to 2016. In total, 26,153 patients (84.7%) underwent RNU and 4,708 (15.3%) underwent SU.

Overall, patients who underwent SU were older; were more likely to have surgery at an academic/research hospital; had lower cT, cN, pT, and pN stages; had pM0 disease; had low grade tumors; had procedures done through open surgery; and had a higher rate of positive margins (P < .001 for all).

SU for lymph node dissection was more likely, compared with RNU (32.3% vs 23.0%; P < .001). “This was consistent across high-grade tumors, tumors over 2 cm, and pT2-3 disease,” Venkat said.

Among those with lymph node dissection, SU induced higher nodal yields (mean, 6.07 nodes), compared with RNU (mean, 5.69 nodes).

Lastly, SU demonstrated improved median overall survival, compared with RNU (66.1 months vs 64.9 months, respectively; P = .025). However, Venkat noted, this trend was not consistent across the high-risk subgroups, including high-grade tumors (median OS, 53.1 months vs 52.3 months, respectively; P = .14), tumors over 2 cm (58.5 months vs 61.2 months; P = .37), pT2 disease (54.0 months vs 60.3 months; P = .072), and pT4 disease (P = .27).

Venkat and colleagues acknowledged the study was limited by potential selection bias andconfounders because it was a national registry-based study; lack of representation of an international population; detection bias, as patients and clinicians were not blinded; potential coding errors; no central pathology review; unknown templates used for surgical approaches; and potential challenges with clinically staging UTUC.

“Prospective studies are still needed to be done,” Venkat said. “So segmental ureterectomy appears to be non-inferior to radical nephroureterectomy in patients. It does appear that surgeons are having a better level of dissection [with] segmental ureterectomy.”

Reference

1. Venkat S, Lewicki P, Basourakos S, Borregales L, Scherr D. Comparison of Radical Nephroureterectomy and Segmental Ureterectomy in Upper Tract Urothelial Carcinoma. Presented at: SUO 22nd Annual Meeting; December 1-3, 2021; Orlando, Florida. Poster 114.