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Purpose: Adjuvant chemotherapy (AC) is recommended for muscle-invasive or lymph node-positive upper urinary tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). However, disease recurrences are frequently observed in pT1 disease, and AC may increase the risk of overtreatment in pT2 UTUC patients. This study aimed to validate a risk-adapted scoring model for selecting UTUC patients with ≤pT2 disease who would benefit from AC. Materials and Methods: We retrospectively analyzed 443 ≤pT2 UTUC patients who underwent RNU. A risk-adapted scoring model was applied, categorizing patients into low- or high-risk groups. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were analyzed according to risk group. Results: Overall, 355 patients (80.1%) and 88 patients (19.9%) were categorized into the low- and high-risk groups, respectively, with the latter having higher pathological stages, concurrent carcinoma in situ, and synchronous bladder tumors. Disease recurrence occurred in 45 patients (10.2%), among whom 19 (5.4%) and 26 (29.5%) belonged to the low- and high-risk groups, respectively (p<0.001). High-risk patients had significantly shorter RFS (64.3% vs. 93.6% at 60 months; hazard ratio [HR] 13.66; p<0.001) and worse CSS (80.7% vs. 91.5% at 60 months; HR 4.25; p=0.002). Multivariate analysis confirmed that pT2 stage and the high-risk group were independent predictors of recurrence and cancer-specific death (p<0.001). Decision curve analysis for RFS showed larger net benefits with our model than with the T stage model. Conclusions: The risk-adapted scoring model effectively predicts recurrence and identifies optimal candidates for AC post RNU in non-metastatic UTUC. [ABSTRACT FROM AUTHOR]

Robotic-assisted laparoscopic nephroureterectomy (NU) became the gold standard in the treatment of upper tract urothelial cancer (UTUC). Usually, a transabdominal approach is used. However, this approach is flawed because of the problematic range of motion and conflicting instruments, especially during the preparation of the ureter orifice in the deep pelvis. We have recently published a novel approach for nephrectomy and partial nephrectomy using the transabdominal lumbar approach (TALA). Using the DaVinci Xi system's rotation possibility, we modified TALA for NU. This includes an un- and redocking step with a 180° rotation of the robot before the dissection of the distal ureter. We have analysed the outcome of all consecutive patients who underwent DRONE at our institution. Between June 2022 and September 2024, we performed Drone on 14 patients and analysed the outcome of 13 patients (10 male/3 female, aged 55–86). The median Operation time was 226 min (158–361). Rotation time was 9 min (6–15). Median blood loss was 100 ml (0–400). Median length of stay was 6 days (5–13). Two patients had Clavien–Dindo complication (CDC) grade 2 complications, and one patient required open revision due to postoperative bleeding and intensive care corresponding to a CDC grade 4a. Our first promising report reveals that the DRONE technique is feasible and safe. The rotation step only took a few minutes and, therefore, seems straightforward. We believe that DRONE facilitates robotic NU by enhancing the range of motion and reducing instrument conflicts. [ABSTRACT FROM AUTHOR]

Simple Summary: This study focuses on robotic radical nephroureterectomy performed for patients with urothelial carcinoma in their kidneys and ureters. The da Vinci Xi platform, which enhances minimally invasive surgical techniques was applied. We aimed to optimize the surgical approach by reducing the number of ports used, and improving visualization during the procedure. The study involved 15 patients operated on by a single surgeon between 2019 and 2024, using a one docking, three-port technique. The median operative time was 133 min, and most surgeries were completed within 150 min. Blood loss was minimal, and complication rate was low. In conclusion, the study highlights that the three-port technique combined with the Xi platform is a safe and effective method for performing robotic radical nephroureterectomy, facilitating quicker procedures and achieving surgical goals. Objective: Nephroureterectomy (NU) is a challenging multi-quadrant surgical procedure that involves intra–infra- and retroperitoneal dissection. The introduction of the da Vinci Xi platform has further improved the minimally invasive approach. With the Xi robotic system, single docking for multi-quadrant dissection is now feasible and increasingly popular. Herein, we redefined the surgical technique by optimizing minimal port usage, maximizing template visualization, and utilizing the Xi platform's retargeting system, based on our experience with 15 patients. Methods: This single-center cohort study was based on the experience of a single surgeon with 15 patients who underwent robotic radical nephroureterectomy (RRNU) between 2019 and 2024, performed via the one docking, three-port technique. Patient data were retrospectively collected and analyzed from the medical records. Results: The cohort's median age was 79 years, with male predominance of 80%. The median operative time was 133 min, with 60% of procedures completed within 150 min; longer times (>150 min) were due to additional intraoperative non-robotic procedures. Median blood loss was 100 mL, with two patients requiring intraoperative blood transfusion. Lymph node dissection (LND) in six patients did not significantly affect the overall operative time. The intraoperative and major postoperative complication rates (Clavien-Dindo grade > III) were 13.3%. Conclusions: The use of three robotic ports combined with the Xi platform's camera-hop feature is a safe and effective technique for multi-quadrant, minimally invasive procedures, particularly in RRNU. This approach facilitates procedural goals and reduces overall operative time. [ABSTRACT FROM AUTHOR]

Purpose: To present the clinical outcomes of nephroureterectomy with bladder cuff excision (NU-BCE) or radical cystectomy (NU-RC) when distal ureteral carcinoma invaded muscle of the ureteral orifice using inverse probability of treatment weighting (IPTW). Methods: This multicenter study retrospectively studied the demographics and perioperative outcomes of 59 patients who underwent NU-BCE or NU-RC between 2003 and 2024. Relapse-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were presented using Kaplan–Meier curves. Cox proportional hazard regression to find independent predictors. Results: Of all patients, the median follow-up time for RFS was 8 months and 18 months for CSS and OS. After IPTW, the median RFS, CSS, and OS for patients who underwent NU-BCE and NU-RC was 9 vs. 27 months (p = 0.037), 18 vs. 40 months (p = 0.027), 18 vs. 30 months (p = 0.371), respectively. The mortality due to progression and complications in NU-BCE and NU-RC patients were 56.4% vs. 20.4% and 2.2% vs. 22.9% (p = 0.016). NU-BCE reduced the median operation time, blood loss, and drainage volume. Apart from NU-RC (HR, 0.18; 95%CI: 0.08–0.44; p < 0.001) (HR, 0.28; 95%CI: 0.1–0.79; p = 0.016) and tumor volume(HR, 1.17; 95%CI: 1.06–1.29; p = 0.002) (HR, 1.21; 95%CI: 1.11–1.31; p < 0.001), which are independent prognostic factors for RFS and CSS, another independent prognostic factor for CSS is the ureteral carcinoma with renal pelvic carcinoma (HR, 4.32; 95%CI: 1.28–14.511; p = 0.018). Conclusions: Patients who underwent NU-RC had better RFS and CSS than NU-BCE, but there was little difference in OS due to the higher mortality rate of postoperative complications in the NU-RC. [ABSTRACT FROM AUTHOR]

Background: This study investigated the utilization of kidney-sparing surgery (KSS) as an alternative option to radical nephroureterectomy (RNU) in managing upper urinary tract urothelial carcinoma (UTUC) patients. Objective: Our study aimed to compare the functional outcomes and oncological outcomes between KSS and RNU. Material and Methods: We retrospectively analyzed 252 patients with UTUC without clinical node positivity or metastasis who had been treated with either RNU or KSS. We collected information on each patient, including clinicopathological factors, renal function variations, and oncological outcomes. Hemodialysis-free survival (HDFS), stage 4 chronic kidney disease (CKD4) progression-free survival (PFS), recurrence-free survival (RFS), and overall survival (OS) were assessed using inverse probability of treatment weighting (IPTW)-weighted Kaplan–Meier analysis. The hazard ratio for oncological and functional outcomes of KSS was analyzed using the Cox proportional hazards model. Results: The OS at 8 years was 77.06% (RNU) and 70.59% (KSS) and did not significantly differ between the two groups (p = 0.691), although the KSS group experienced a higher recurrence rate. Functional outcomes indicated no significant difference in postoperative renal function at 1 year; however, KSS was associated with better preservation of renal function (23.44% vs. 28.23%), albeit not statistically significant (p = 0.055). Kaplan–Meier analysis revealed no significant disparities in CKD4 PFS between the KSS and RNU groups involved in the study (p = 0.089), although the KSS group displayed poorer HDFS than the RNU group (p = 0.001). Conclusion: KSS had no compromising survival outcomes when compared with RNU, not only in low-risk patients but also in high-risk patients with a normal contralateral kidney. The efficacy of renal function preservation was presented in this study, however the results were below our expectations. [ABSTRACT FROM AUTHOR]

Abstract Objective This study aims to explore the relationship between pre-existing renal impairment and oncological outcomes in upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU) using data from a multicentre international registry. Patients and methods Data on non-metastatic UTUC patients who underwent RNU were obtained from the Clinical Research Office of the Endourology Society Urothelial Carcinomas of the Upper Tract (CROES-UTUC) Registry. Patients were categorised into normal pre-operative renal function and chronic renal impairment (CKD) groups, with CKD defined as an estimated glomerular filtration rate below 60 mL/kg/1.73 m². Kaplan–Meier survival analysis was employed to investigate disease-free survival (DFS) and overall survival (OS). Multivariable Cox regression analysis was conducted to identify confounding variables. Results A total of 1393 patients diagnosed with UTUC who underwent RNU between 2014 and 2019 were analysed. 875 patients (62.4%) had normal renal function, whilst 528 patients (37.6%) had CKD prior to RNU. The two groups had similar proportions of bladder cancer history, comparable cardiovascular comorbidity, similar tumour stage, and comparable proportions receiving laparoscopic or robotic-assisted RNU. In multivariable cox regression analysis, CKD was found to be associated with inferior DFS (HR = 1.419; 95%CI = 1.060–1.898; p = 0.019). Upon multivariable analysis, pre-existing renal impairment and higher T stage (HR = 4.613; 95%CI = 1.829–4.712; p

ABSTRACT Introduction: We aim to compare the safety and effectiveness of the KangDuo (KD)-Surgical Robot-01 (KD-SR-01) system and the da Vinci (DV) system for robot-assisted radical nephroureterectomy (RARNU). Materials and Methods: This multicenter prospective randomized controlled trial was conducted between March 2022 and September 2023. Group 1 included 29 patients undergoing KD-RARNU. Group 2 included 29 patients undergoing DV-RARNU. Patient demographic and clinical characteristics, perioperative data, and follow-up outcomes were collected prospectively and compared between the two groups. Results: There were no significant differences in patient baseline demographic and preoperative characteristics between the two groups. The success rates in both groups were 100% without conversion to open or laparoscopic surgery or positive surgical margins. No significant difference was observed in docking time [242 (120-951) s vs 253 (62-498) s, P = 0.780], console time [137 (55-290) min vs 105 (62-220) min, P = 0.114], operative time [207 (121-460) min vs 185 (96-305) min, P = 0.091], EBL [50 (10-600) mL vs 50 (10-700) mL, P = 0.507], National Aeronautics and Space Administration Task Load Index scores, and postoperative serum creatinine levels between the two groups. None of the patients showed evidence of distant metastasis, local recurrence, or equipment-related adverse events during the four-week follow-up. One (3.4%) patient in Group 2 experienced postoperative enterovaginal and enterovesical fistulas (Clavien-Dindo grade III). Conclusions: The KD-SR-01 system is safe and effective for RARNU compared to the DV Si or Xi system. Further randomized controlled studies with larger sample sizes and longer durations are required.

Objective Methods Results Conclusions To investigate the prevalence, predictors and impact of surgically induced chronic kidney disease (CKD‐S) on survival outcomes in patients with upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU).Utilising the ROBUUST 2.0 registry, a multicentre retrospective analysis was conducted in patients with UTUC undergoing RNU between 2006 and 2022 who did not have baseline chronic kidney disease (CKD) stages 3–5. We calculated the prevalence of postoperative CKD‐S3a (estimated glomerular filtration rate [eGFR] 59–45 mL/min/1.73 m2) and CKD‐S3b (eGFR <45 mL/min/1.73 m2) as measured by the Chronic Kidney Disease Epidemiology Collaboration 2021 equation. The analytical cohort was stratified by postoperative CKD stage [no CKD‐S [eGFR ≥60 mL/min/1.73 m2]; CKD‐S3a [eGFR 59–45 mL/min/1.73 m2] and CKD‐S3b [eGFR <45 mL/min/1.73 m2]). The primary outcome was all‐cause mortality (ACM). Predictors for development of CKD‐S3a/3b and ACM/cancer‐specific mortality (CSM) were analysed using logistic and Cox regression, respectively. Kaplan–Meier analysis was used to analyse overall survival (OS) and cancer‐specific survival (CSS) among postoperative CKD groups.We analysed 1862 patients; 34.7% (646) and 39.6% (738), respectively, developed CKD‐S3a and CKD‐S3b. Predictors of CKD‐S3b included increasing age (odds ratio [OR] 1.03, P = 0.029), decreasing preoperative eGFR (OR 1.06, P < 0.001) and receipt of neoadjuvant (OR 2.07, P = 0.006) and adjuvant chemotherapy (OR 1.41, P = 0.012). Worsened ACM was associated with CKD‐S3b (hazard ratio 1.42, P = 0.032), but not CKD‐S3a (P = 0.766). Development of CKD‐S3a (P = 0.812) and CKD‐S3b (P = 0.316) were not associated with CSM. The 5‐year OS rate was significantly worse in CKD‐S3b (no‐CKD 71%, CKD‐S3a 70%, CKD‐S3b 59%; P = 0.017). No differences between CKD‐S groups were noted for 5‐year CSS (no‐CKD 78%, CKD‐S3a 77%, CKD‐S3b 82%; P = 0.44).A significant proportion of UTUC patients undergoing RNU developed CKD‐S. Development of CKD‐S3b was associated with worse ACM. Increasing age, preoperative eGFR, and chemotherapy were associated with developing CKD‐S3b. Our findings call for further exploration and refinement of nephron‐preserving surgical strategies and non‐nephrotoxic systemic therapy to improve survival outcomes in UTUC. [ABSTRACT FROM AUTHOR]

Objective: This study aims to explore the relationship between pre-existing renal impairment and oncological outcomes in upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU) using data from a multicentre international registry. Patients and methods: Data on non-metastatic UTUC patients who underwent RNU were obtained from the Clinical Research Office of the Endourology Society Urothelial Carcinomas of the Upper Tract (CROES-UTUC) Registry. Patients were categorised into normal pre-operative renal function and chronic renal impairment (CKD) groups, with CKD defined as an estimated glomerular filtration rate below 60 mL/kg/1.73 m². Kaplan–Meier survival analysis was employed to investigate disease-free survival (DFS) and overall survival (OS). Multivariable Cox regression analysis was conducted to identify confounding variables. Results: A total of 1393 patients diagnosed with UTUC who underwent RNU between 2014 and 2019 were analysed. 875 patients (62.4%) had normal renal function, whilst 528 patients (37.6%) had CKD prior to RNU. The two groups had similar proportions of bladder cancer history, comparable cardiovascular comorbidity, similar tumour stage, and comparable proportions receiving laparoscopic or robotic-assisted RNU. In multivariable cox regression analysis, CKD was found to be associated with inferior DFS (HR = 1.419; 95%CI = 1.060–1.898; p = 0.019). Upon multivariable analysis, pre-existing renal impairment and higher T stage (HR = 4.613; 95%CI = 1.829–4.712; p < 0.001) and the use of adjuvant chemotherapy (HR = 1.858; 95%CI = 1.229–2.807; p = 0.003) were also found to associate with worse DFS. Significant cardiovascular disease and higher T stage were associated with worse OS. Existing renal impairment at baseline did not have any significant associated with OS. Conclusion: In this multicentre registry, preoperative chronic renal impairment was identified as an independent predictor of inferior DFS in patients undergoing RNU for non-metastatic UTUC. Preoperative CKD could serve as a clinical predictor of poorer oncological outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To assess the impact of neoadjuvant and adjuvant chemotherapy on survival outcomes, within a large multicenter cohort of Upper tract urothelial carcinoma patients treated with Nephroureterectomy. Methods: A multicenter retrospective analysis utilizing the Robotic surgery for Upper Tract Urothelial Cancer Study registry was performed. Baseline, preoperative, perioperative, and pathologic variables of three groups of patients receiving surgery only, neoadjuvant or adjuvant chemotherapy were compared. Categorical and continuous variables among the three subgroups were compared with Chi square and ANOVA tests. The impact of perioperative chemotherapy on survival outcomes was assessed with the Kaplan Meier method. Univariable and multivariable Cox regression analyses were performed to identify predictors of survival. Results: Overall, 1,994 patients were included. Overall and Clavien grade ≥3 complications rates were comparable among the three subgroups (p = 0.65 and p = 0.92). At Kaplan Meier analysis, neoadjuvant chemotherapy significantly improved cancer-specific survival (p = 0.03) and overall survival (p = 0.03) probabilities of patients with cT ≥ 3 tumors and of those with positive cN (p = 0.03 and p = 0.02). On multivariable analysis, neoadjuvant chemotherapy was independently associated with an improvement of cancer-specific survival in cT ≥ 3 patients (HR 0.44; p = 0.04), and of both cancer-specific survival (HR 0.50; p = 0.03) and overall survival (HR 0.53; p = 0.02) probabilities in positive cN patients. Conclusions: This large multicenter retrospective analysis suggests significant survival benefit in Upper tract urothelial carcinoma patients with either locally advanced or clinically positive nodes disease receiving neoadjuvant chemotherapy. These findings can be regarded as "hypothesis generating", stimulating future trials focusing on such advanced stages. [ABSTRACT FROM AUTHOR]

Objectives We studied the diagnostic accuracy and discordance of upper tract urothelial carcinoma (UTUC) by comparing biopsy and urinary cytology with matched nephroureterectomy specimens. Methods Sixty-nine patients with UTUC without neoadjuvant treatment were retrospectively identified who had matched biopsy and nephroureterectomy specimens. Twenty patients had concurrent upper tract cytology. H&E and cytology slides were re-reviewed. Statistical analysis was performed. Results Patients included 48 men and 21 women with a mean age of 69 years. A concordant grade between biopsy and surgical specimen was present in 49 (71%) patients. The mean size of biopsy specimens in the discordant group was significantly smaller than that in the concordant group. Invasion was evaluated in 48 biopsy cases that had adequate subepithelial tissue, and 33 of them were diagnosed with concordant invasion status. Mean tumor size in both tumor grade and invasion discordant groups was significantly larger than that in the concordant group. High-grade urothelial carcinoma was detected in 84% of cases using urinary cytology. Conclusions Our study demonstrates the diagnostic challenges of UTUC on small biopsy specimens. Biopsy specimen size and tumor size are significantly associated with the diagnostic discordance. Upper tract cytology showed high diagnostic accuracy and should be complementary to the biopsy. [ABSTRACT FROM AUTHOR]

Upper tract urothelial carcinoma (UTUC) accounts for 5–10% of urothelial cancers and is associated with high morbidity and mortality. Increasing incidence of UTUC has been observed since the 1970's, alongside the evolution of advance imaging techniques, precision biopsy equipment, and risk stratification models. The high morbidity of radical nephroureterectomy (RNU) which is still the gold-standard treatment for high-risk UTUC, has driven the development of kidney-sparing surgery alternatives for low-risk UTUC. Now, several treatment approaches have outcomes comparable to RNU for low-risk UTUC and guidelines are recommending kidney-sparing surgery for favorable low-risk disease. The main categories of kidney-sparing surgery include segmental ureterectomy, endoscopic ablation, chemoablation, and vascular-targeted phototherapy. These treatments are highly nuanced making them difficult to compare, but for most cases of favorable low-grade disease, we recommend endoscopic laser ablation with optional adjuvant intracavitary therapy. Adverse events associated with kidney-sparing surgery include ureteral stricture, bleeding requiring transfusion, and bladder recurrence of UTUC. Limitations of kidney-sparing surgery include appropriate tissue sampling (contributing to under-grading and under-staging), higher rates of ipsilateral recurrence, and potential for grade and stage progression. Collectively, these may subsequently necessitate RNU. Here, we review the technical variations and evidence behind kidney-sparing therapies as well as their practicality in the real world. [ABSTRACT FROM AUTHOR]

Background and objectives: To investigate the risk factors of renal function deterioration after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Methods: A total of 153 patients with UTUC who underwent radical surgery at a high-volume center in China from January 2015 to December 2019 were included in this study. The renal function of all patients was evaluated during follow-up. Besides, these patients were grouped according to postoperative renal function. The risk factors of renal function deterioration included age, sex, body mass index (BMI), T stage, tumor location and size, lymph node invasion, lymph node dissection (LND), surgical margin, tumor histology, lymphovascular invasion (LVI), hypertension, diabetes, hematuria, blood transfusion, hydronephrosis on the affected side, urine specific gravity, creatinine, uric acid, and preoperative glomerular filtration rate (GFR) on the healthy and affected sides. The correlation between risk factors and inclusion indexes was analyzed using univariate and multivariate analyses. Results: A total of 153 patients were enrolled in this study, and the follow-up continued for 14 (11, 24) months. Acute kidney injury (AKI) was diagnosed in 65 patients in the short-term follow-up after RNU, and renal function deterioration was diagnosed in 52 patients in the long-term follow-up after RNU. The univariate analysis of 65 patients with short-term AKI revealed that there were statistically significant differences in preoperative hydronephrosis, hypertension, urinary protein, tumor size, preoperative Hb, preoperative creatinine, blood transfusion, and preoperative GFR of the healthy kidney. The multivariate Logistic regression analysis results showed that preoperative creatinine, GFR of the healthy kidney, and blood transfusion were independent risk factors for AKI. Moreover, The multivariate Logistic regression analysis of 52 patients with long-term renal insufficiency after surgery indicated that there were statistically significant differences in preoperative hydronephrosis, tumor size, preoperative GFR of the healthy kidney, and postoperative AKI. Conclusion: For patients with UTUC, the preoperative creatinine level is high, blood transfusion was given during or after procedure and the GFR of the healthy kidney is low, it is easy to have AKI in the short term after operation. In addition, there was no hydronephrosis before operation, the tumor size was small, the GFR of the healthy kidney was low before operation, AKI occurred after operation, the renal function was easy to deteriorate for a long time after operation. The above risk factors may aggravate renal function deterioration of these patients after surgery, resulting in the loss of the opportunity to continue treatment. [ABSTRACT FROM AUTHOR]

This article discusses a surgical technique called single-port robot-assisted nephroureterectomy (RANU) for the treatment of upper tract urothelial carcinoma (UTUC). The technique utilizes the da Vinci Single Port System (SP), which allows for smaller incisions and improved outcomes compared to multiport systems. The article provides a detailed description of the surgical technique and reports positive results in terms of operative time, blood loss, complications, pain scores, and length of stay. The authors suggest that further research comparing SP RANU to other techniques is needed, but believe it has the potential to be a competitive option for UTUC treatment. [Extracted from the article]

Introduction and Hypothesis: Robot-assisted radical nephroureterectomy (RANU) has emerged as a valid alternative to open or laparoscopic nephroureterectomy in recent years. However, different types of robotic platforms can limit surgical maneuvers in various ways. This study aimed to describe the surgical procedure and demonstrate RANU's technical feasibility and safety using the Hugo robot-assisted surgery (RAS) system. Materials and Methods: Using the Hugo RAS system, we reported data from the first five consecutive patients who underwent RANU at Tottori University Hospital. We adjusted the docking angles of the four independent arm carts in each case and performed a complete RANU via a transperitoneal approach. We collected patients' sociodemographic and perioperative data, including complications, and compared them retrospectively with data obtained using the da Vinci surgical system. Results: Arms positions were modified after the first patient to be placed all at the back of the patient. Median overall operative time was 283 minutes (203–377) and the median time using the robotic system was 187 minutes (121–277). The median estimated blood loss was 20 mL (5–155). None of the patients required a blood transfusion and none suffered postoperative complications of Clavien–Dindo grade ≥3. These outcomes were similar to those obtained with the da Vinci Xi system. Conclusion: This series represents the first report of RANU executed using the novel Hugo RAS system. Our proposed arm-setup will assist other surgeons and help ensure safe implementation of RANU on the Hugo platform. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic management of upper tract urothelial carcinoma (UTUC) is increasingly relevant with greater detection of low-grade disease and guidelines recommending kidney preservation for low-risk disease. Historically, laser or thermal ablation has served as the primary tool for endoscopic management of UTUC, however, chemoablation is rapidly being developed to serve as a primary or adjuvant treatment option, which warrants review. Areas Covered: The current literature was reviewed to compare the outcomes and clinical utility of endoscopic treatment modalities for low-grade UTUC, with a focus on mitomycin-containing reverse thermal gel (UGN-101). Expert Opinion: The overall outcomes of mitomycin-containing gel therapy are promising, but adverse effects such as ureteral stricture call for careful consideration when using this treatment. We believe it is reasonable to consider use of mitomycin-containing gel as an adjuvant chemotherapy with endoscopic laser resection of low-grade upper tract urothelial carcinoma. [ABSTRACT FROM AUTHOR]

Background: It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions. Objective: The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU). Methods: Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models. Results: Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20–1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001). Conclusions: Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of laparoscopic nephroureterectomy (LNU) vs open nephroureterectomy (ONU) for upper tract urothelial carcinoma (UTUC) is unclear. Methods: We conducted a meta-analysis of studies based on propensity score-matched cohorts to compare the surgical and oncological outcomes of LNU and ONU in UTUC patients. A literature search was conducted on PubMed, Embase, and Cochrane Library until July 12, 2023. The Newcastle-Ottawa Scale was utilized to assess the quality of eligible studies. Measurements of surgical and oncological outcomes were extracted and pooled including mean difference (MD), risk ratio (RR), hazard ratios (HR), and 95% confidence intervals (CI). Results: Five high-quality retrospective studies were included, totaling 6422 patients; 2080 (32.4%) underwent LNU, and 4342 (67.6%) underwent ONU. With respect to surgical outcomes, patients in the LNU group experienced less estimated blood loss and had shorter hospital stay than those in the ONU group, but there was no significant difference in complication rates and operation time. In regard to oncological outcomes, there were no significant differences between the LNU and ONU groups in 3-year overall survival (OS) and cancer-specific survival (CSS). However, 3-year intravesical recurrence free survival (IVRFS) was worse in the LNU group compared to the ONU group. Conclusion: LNU was associated with less estimated blood loss and shorter hospital stays than ONU, but there were no differences in OS and CSS between the surgical modalities. Nonetheless, LNU might result in poorer IVRFS than ONU. [ABSTRACT FROM AUTHOR]

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A thoracic kidney is a scarce type of ectopic kidney. We report the case of a 76-year-old man who developed cancer of the ureter, ipsilateral to the thoracic kidney. He presented with abdominal pain in the right upper quadrant. Computed tomography revealed a right hydronephrotic kidney located in the thorax with elevation of the diaphragm. Further examination uncovered a cT2N0M0 ureteral cancer in the right upper ureter. A laparoscopic radical right nephroureterectomy was performed using a retroperitoneal approach. The retroperitoneal space was created for the usual port placement. A port between the 11th and 12th ribs was added to facilitate handling the suprahilar area, specifically the dissection of the superior aspect and separation of the kidney without accompanying pneumothorax. To our knowledge, this is the first report of a successful complete laparoscopic surgery via the retroperitoneal approach for a malignant disease associated with a thoracic kidney. [ABSTRACT FROM AUTHOR]

Simple Summary: This research investigates whether a diagnostic technique called ureteroscopy (URS), performed before surgery for removing the kidney and ureter, influences the likelihood of cancer recurrence in the bladder in patients with upper tract urothelial carcinoma (UTUC). Data from a multicentre international registry were analysed to compare patients who underwent URS before their surgery with those who did not. The study found that patients who had URS prior to surgery experienced a higher rate of cancer recurrence in the bladder. These results highlight the need for careful consideration of the use of URS in the diagnostic process for UTUC, as it could affect long-term outcomes. This information is crucial for clinicians in optimizing treatment strategies and improving patient care. (1) Introduction: Diagnostic ureteroscopy (URS) is an important component in the workup of upper tract urothelial carcinoma (UTUC). Whether URS was associated with increased recurrence in the bladder was not fully concluded. The current study aimed to evaluate the implication of URS on the incidences of intravesical recurrence following radical nephroureterectomy (RNU) in non-metastatic UTUC patients without prior history of bladder cancer via multi-institutional data. (2) Patients and Methods: Data were obtained from the Clinical Research Office of the Endourology Society Urothelial Carcinomas of the Upper Tract (CROES-UTUC) registry, a prospective, multicentre database. Patients with non-metastatic UTUC treated with RNU were divided into two groups: those undergoing upfront RNU and those having diagnostic URS prior to RNU. Intravesical recurrence-free survival (IVRS) was the primary endpoint, evaluated through Kaplan–Meier analysis and multivariate Cox regression. Cases with adequate follow-up data were included. (3) Results: The analysis included 269 patients. Of these, 137 (50.9%) received upfront RNU and 132 (49.1%) received pre-RNU URS. The URS group exhibited an inferior 24-month IVRS compared to the upfront RNU group (HR = 1.705, 95% CI = 1.082–2.688; p = 0.020). Multivariate analysis confirmed URS as the only significant predictor of IVR (p = 0.019). Ureteric access sheath usage, flexible ureteroscopy, ureteric biopsy, retrograde contrast studies, and the duration of URS did not significantly affect IVRS. (4) Conclusions: Diagnostic URS prior to RNU was found to be associated with an increased risk of IVR in patients with UTUC. The risk was not significantly influenced by auxiliary procedures during URS. Physicians were advised to meticulously evaluate the necessity of diagnostic URS. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to assess the effectiveness of early single intravesical administration of epirubicin in preventing intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma. Materials and Methods: Patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy between November 2018 and May 2022 were retrospectively reviewed. Intravesical epirubicin was administered within 48 hours if no evidence of leakage was observed. Epirubicin (50 mg) in 50 mL normal saline solution was introduced into the bladder via a catheter and maintained for 60 minutes. The severity of adverse events was graded using the Clavien-Dindo classification. We compared intravesical recurrence rate between the two groups. Multivariate analyses were performed to identify the independent predictors of bladder recurrence following radical nephroureterectomy. Results: Epirubicin (n=55) and control (n=116) groups were included in the analysis. No grade 1 or higher bladder symptoms have been reported. A statistically significant difference in the intravesical recurrence rate was observed between the two groups (11.8% at 1 year in the epirubicin group vs. 28.4% at 1 year in the control group; log-rank p=0.039). In multivariate analysis, epirubicin instillation (hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.20 to 0.93; p=0.033) and adjuvant chemotherapy (HR, 0.29; 95% CI, 0.13 to 0.65; p=0.003) were independently predictive of a reduced incidence of bladder recurrence. Conclusion This retrospective review revealed that a single immediate intravesical instillation of epirubicin is safe and can reduce the incidence of intravesical recurrence after radical nephroureterectomy. However, further prospective trials are required to confirm these findings. [ABSTRACT FROM AUTHOR]

Abstract Background Upper tract urothelial carcinoma (UTUC) is a rare malignancy, with typically only few new cases annually per urological department. Adherence to European association of urology (EAU) guidelines on UTUC in the Nordic countries is unknown. The objective of this survey was to examine the implementation of EAU guidelines, the perioperative management and organization of the treatment of UTUC in the Nordic countries. Methods The electronic survey was distributed to 93 hospitals in the Nordic countries performing radical nephroureterectomy (NU). The survey consisted of 57 main questions and data was collected between December 1st, 2021 and April 23rd, 2022. Results Overall response rate was 47/93 (67%) with a completion rate of 98%. Five out of the 6 examined subjects on diagnostic practice are applied by ≥ 72% of the participating centers. NU as treatment for high-risk UTUC is performed by 37/47 (79%), and 91% include a bladder cuff excision. Conclusions Adherence to EAU guidelines is high on diagnostic practice in the Nordic countries, whereas disease management is less coherent.

Background: Upper tract urothelial carcinoma (UTUC) is a rare malignancy, with typically only few new cases annually per urological department. Adherence to European association of urology (EAU) guidelines on UTUC in the Nordic countries is unknown. The objective of this survey was to examine the implementation of EAU guidelines, the perioperative management and organization of the treatment of UTUC in the Nordic countries. Methods: The electronic survey was distributed to 93 hospitals in the Nordic countries performing radical nephroureterectomy (NU). The survey consisted of 57 main questions and data was collected between December 1st, 2021 and April 23rd, 2022. Results: Overall response rate was 47/93 (67%) with a completion rate of 98%. Five out of the 6 examined subjects on diagnostic practice are applied by ≥ 72% of the participating centers. NU as treatment for high-risk UTUC is performed by 37/47 (79%), and 91% include a bladder cuff excision. Conclusions: Adherence to EAU guidelines is high on diagnostic practice in the Nordic countries, whereas disease management is less coherent. [ABSTRACT FROM AUTHOR]

To assess the oncologic efficacy and safety of robot-assisted approach to radical nephroureterectomy (RARNU) in geriatric versus younger patients with upper tract urothelial carcinoma (UTUC). A single-center, retrospective cohort study was conducted from 2009 to 2022 of 145 patients (two cohorts: < 75 and ≥ 75 years old) with non-metastatic UTUC who underwent RARNU. Primary endpoint was UTUC-related recurrence of disease during surveillance (bladder-specific and metastatic). Safety was assessed according to 30-day, modified Clavien–Dindo (CD) classifications (Major: C.D. III–V). Survival estimates were performed using Kaplan–Meier method. There were 89 patients < 75 years (median 65 years) and 56 patients ≥ 75 years (median 81 years). Comparing the young versus geriatric cohorts: median follow-up 38 vs 24 months (p = 0.03, respectively) with similar 3-year bladder-specific recurrence survival (60% vs 67%, HR 0.70, 95% CI [0.35, 1.40], p = 0.31) and metastasis-free survival (79% vs 70%, HR 0.71, 95% CI [0.30, 1.70], p = 0.44). Expectedly, the younger cohort had a significant deviation in overall survival compared to the geriatric cohort at 1-year (89% vs 76%) and 3-years (72% vs 41%; HR 3.29, 95% CI [1.88, 5.78], p < 0.01). The 30-day major (1% vs 0) and minor complications (8% vs 14%, p = 0.87). Limitations include retrospective study design of a high-volume, single-surgeon experience. Compared to younger patients with UTUC, geriatric patients undergoing RARNU have similar oncologic outcomes at intermediate-term follow-up with no increased risk of 30-day perioperative complications. Thus, age alone should not be used to disqualify patients from definitive surgical management of UTUC with RARNU. [ABSTRACT FROM AUTHOR]

The management of urothelial carcinoma has evolved with the introduction of minimally invasive techniques such as laparoscopic or robotic procedures, challenging the traditional approach of open surgery, and giving rise to atypical recurrences (ARs). ARs include port-site metastasis and peritoneal carcinomatosis, yet discrepancies persist among authors regarding their precise classification. Incidence rates of ARs vary widely across studies, ranging from less than 1% to over 10% in both muscle-invasive bladder cancer (MIBC) and upper tract urothelial tumor (UTUC). Peritoneal metastases predominate as the most common ARs in patients with MIBC, while retroperitoneal metastases are prevalent in those with UTUC due to differing surgical approaches. The timing of AR presentation and survival outcomes closely mirror those of conventional recurrences, with which they are frequently associated. Pneumoperitoneum has progressively been regarded less as the cause of ARs, while surgical-related risk factors have gained prominence. Current major surgical-related causes include tumor spillage and urinary tract violation during surgery, avoidance of endo bag use for specimen extraction, and low surgical experience. Factors such as tumor stage, histological variants, and lympho-vascular invasion correlate with the risk of ARs, suggesting a close association with tumor biology. Further studies are required to better understand the incidence, risk factors, characteristics, and outcomes of ARs. [ABSTRACT FROM AUTHOR]

Technique modifications that aim to improve ergonomics of the surgical procedure without repositioning the upper tract urothelial carcinoma patients remain a challenge to urologists. We offer a novel technique to perform intraperitoneal laparoscopic single-site radical nephroureterectomy and pelvic lymph nodes dissection/retroperitoneal lymph nodes dissection in a supine position. Our novel technique is feasible and offers a significant improvement in operative efficiency, particularly in patients with locally advanced disease. [ABSTRACT FROM AUTHOR]

A 62-year-old woman presented with right flank pain. Computed tomography and retrograde pyelogram showed right hydronephrosis and stenosis in the lower ureter. The ureteral biopsy results were difficult to differentiate from malignancy, and accordingly a total nephroureterectomy was performed. Pathological examination revealed localized amyloidosis of the left ureter. The patient has been free of recurrence for 5 months since the surgery. Localized amyloidosis of the ureter is a rare entity. Clinical features are similar to those of ureteral tumor. We report the case of localized amyloidosis of the ureter, with some discussion of the literature. [ABSTRACT FROM AUTHOR]

Objective: The report aims to present a rare bilateral UTUC focusing on diagnostic and surgical treatment to improve the survival rate of patients with bilateral UTUC. Case(s) Presentation: We present a case report of a 59-year-old male who came in with gross hematuria accompanied with clots. Laboratory reveals a decreased renal function, while CT shows a bilateral mass in both ureters and left renal pelvis without bladder involvement. The patient then underwent left nephroureterectomy and right ureterectomy. In Intraoperative we preserve the right kidney by evaluating the tumor margin using ultrasound and ureteroscopy and deciding to substitute a full-length ureter with ileum as a precaution for a safety margin. Later on the pathological examination shown high-grade invasive urothelial cell carcinoma on both sides with staging pT2N0M0. Six months after surgery patient is in an excellent condition; weight and karnofsky score improvement. The Baseline Creatinin level was decreased, whereas CT showed no residual tumor in the right urinary tract system. Discussion: This article presents a rare case of bilateral UTUC with staging pT2N0M0 that was successfully treated with multidisciplinary care of radical and reconstructive surgery without chemotherapy. Conclusion: Bilateral UTUC is a scarce case, even among all urologic malignancies. Preserving kidney function in these cases is a priority to reduce further morbidity for the patient. Keywords: Bilateral UTUC, nephroureterectomy, ileoureteral replacement.

Abstract Background Limited information is available for guiding the management of upper urinary tract (UUT) urothelial carcinoma with squamous differentiation (UC-SqD). We did not even know about the difference between pure urothelial carcinoma (UC) and UC-SqD in the UUT regardless of treatment policy and prognosis. Instead of direct comparisons against each other, we included the third UUT malignancy, squamous cell carcinoma (SCC). This three-way-race model allows us to more clearly demonstrate the impact of squamous cell transformation on patient outcomes in UUT malignancy. Methods We retrospectively analysed 327 patients with UC, UC-SqD, or SCC who underwent radical nephroureterectomy with bladder cuff excision (RNU) at Taichung Veterans General Hospital, Taichung, Taiwan, between January 2006 and December 2013. A Kaplan–Meier survival analysis was used to evaluate the relationship between patient outcomes and histology. Multivariate Cox proportional hazards modelling was also used to predict patient prognoses. Results The five-year postoperative cancer-specific survival (CSS) rates were 83.6% (UC), 74.4% (UC-SqD), and 55.6% (SCC), and the 5-year recurrence-free survival (RFS) rates were 87.7% (UC), 61.5% (UC-SqD), and 51.9% (SCC). UC patients had significantly better 5-year RFS than UC-SqD and SCC patients (P = 0.001 and P

We present the trial-and-error process of standardizing robot-assisted radical nephroureterectomy (RANU) at a high-volume center in Japan. Our urology team performed 53 RANU cases using the Da Vinci Xi system, undergoing five major evolutionary stages. We performed RANU via transperitoneal approach in all cases and lymph-node dissection in selected cases. During the evolution, we adopted a lithotomy position and significantly modified port placement to facilitate lower ureter management. However, we ultimately arrived at a method that minimizes port and patient repositioning during lower ureter processing. By strategically placing ProGrasp™ forceps in the most caudal port, we effectively retracted the bladder and grasped the opened bladder wall during lower ureter manipulation. This approach also allowed us to perform pelvic, para-aortic, and renal portal lymph-node dissection without major changes in patient positioning or port placement. Nevertheless, we acknowledge that some variations in positioning and techniques may be necessary depending on specific case requirements. [ABSTRACT FROM AUTHOR]

Introduction Most congenital ureteral strictures occur at the ureteropelvic or ureterovesical junction in children. Mid‐ureteral stricture is very rare and can cause congenital hydronephrosis. Only a few studies have reported on coexisting mid‐ureteral stricture with ipsilateral atrophic kidney in young adults. Case presentation A 16‐year‐old girl presented with repeated urinary tract infection. Computed tomography revealed a right atrophic kidney and hydroureter. Retrograde pyelography showed a mid‐ureteral stricture. Laparoscopic nephroureterectomy was performed, and histological examination revealed mid‐ureteral stricture with hyperplasia of the fibrous connective tissue and an atrophic kidney. Conclusion Mid‐ureteral stricture in a young adult is extremely rare. Appropriate imaging studies including retrograde pyelography are necessary for accurate diagnosis of mid‐ureteral stricture.

The detection of plasma circulating tumor DNA (ctDNA) in high-risk upper tract urothelial carcinoma prior to extirpative surgery was highly predictive of muscle-invasive and non–organ-confined staging, and strongly prognostic for progression-free and overall survival. Preoperative ctDNA demonstrates promise as a biomarker for selecting patients to undergo neoadjuvant chemotherapy prior to nephroureterectomy. Optimal patient selection for neoadjuvant chemotherapy prior to surgical extirpation is limited by the inaccuracy of contemporary clinical staging methods in high-risk upper tract urothelial carcinoma (UTUC). To investigate whether the detection of plasma circulating tumor DNA (ctDNA) can predict muscle-invasive (MI) and non–organ-confined (NOC) UTUC. Plasma cell-free DNA was prospectively collected from chemotherapy-naïve, high-risk UTUC patients undergoing surgical extirpation and sequenced using a 152-gene panel and low-pass whole-genome sequencing. To test for concordance, whole-exome sequencing was performed on matching tumor samples. The performance of ctDNA for predicting MI/NOC UTUC was summarized using the area under a receiver-operating curve, and a variant count threshold for predicting MI/NOC disease was determined by maximizing Youden's J statistic. Kaplan-Meier methods estimated survival, and Mantel-Cox log-rank testing assessed the association between preoperative ctDNA positivity and clinical outcomes. Of 30 patients enrolled prospectively, 14 were found to have MI/NOC UTUC. At least one ctDNA variant was detected from 21/30 (70%) patients, with 52% concordance with matching tumor samples. Detection of at least two panel-based molecular alterations yielded 71% sensitivity at 94% specificity to predict MI/NOC UTUC. Imposing this threshold in combination with a plasma copy number burden score of >6.5 increased sensitivity to 79% at 94% specificity. Furthermore, the presence of ctDNA was strongly prognostic for progression-free survival (PFS; 1-yr PFS 69% vs 100%, p < 0.001) and cancer-specific survival (CSS; 1-yr CSS 56% vs 100%, p = 0.016). The detection of plasma ctDNA prior to extirpative surgery was highly predictive of MI/NOC UTUC and strongly prognostic of PFS and CSS. Preoperative ctDNA demonstrates promise as a biomarker for selecting patients to undergo neoadjuvant chemotherapy prior to nephroureterectomy. Here, we show that DNA from upper tract urothelial tumors can be detected in the blood prior to surgical removal of the kidney or ureter. This circulating tumor DNA can be used to predict that upper tract urothelial carcinoma is invasive into the muscular lining of the urinary tract and may help identify those patients who could benefit from chemotherapy prior to surgery. [ABSTRACT FROM AUTHOR]

Background: Limited information is available for guiding the management of upper urinary tract (UUT) urothelial carcinoma with squamous differentiation (UC-SqD). We did not even know about the difference between pure urothelial carcinoma (UC) and UC-SqD in the UUT regardless of treatment policy and prognosis. Instead of direct comparisons against each other, we included the third UUT malignancy, squamous cell carcinoma (SCC). This three-way-race model allows us to more clearly demonstrate the impact of squamous cell transformation on patient outcomes in UUT malignancy. Methods: We retrospectively analysed 327 patients with UC, UC-SqD, or SCC who underwent radical nephroureterectomy with bladder cuff excision (RNU) at Taichung Veterans General Hospital, Taichung, Taiwan, between January 2006 and December 2013. A Kaplan–Meier survival analysis was used to evaluate the relationship between patient outcomes and histology. Multivariate Cox proportional hazards modelling was also used to predict patient prognoses. Results: The five-year postoperative cancer-specific survival (CSS) rates were 83.6% (UC), 74.4% (UC-SqD), and 55.6% (SCC), and the 5-year recurrence-free survival (RFS) rates were 87.7% (UC), 61.5% (UC-SqD), and 51.9% (SCC). UC patients had significantly better 5-year RFS than UC-SqD and SCC patients (P = 0.001 and P < 0.0001, respectively). Patients with pure UC had significantly better 5-year CSS than SCC patients (P = 0.0045). SCC or UC-SqD did not independently predict disease-specific mortality (HR 0.999, p = 0.999; HR 0.775, p = 0.632, respectively) or disease recurrence compared to pure UC (HR 2.934, p = 0.239; HR 1.422, p = 0.525, respectively). Age, lymphovascular invasion (LVI), and lymph node (LN) status independently predicted CSS, while pathological tumour stage, LN status, and LVI predicted RFS. Conclusions: SCC and UC-SqD are not independent predictors of survival outcomes in patients with UUT tumours. However, they are associated with other worse prognostic factors. Hence, different treatments are needed for these two conditions, especially for SCC. [ABSTRACT FROM AUTHOR]

Comprehensive analyses including both metachronous and synchronous metastatic upper tract urothelial carcinoma are limited. In this retrospective cohort study, we evaluated oncologic outcomes and costs associated with management of metastatic upper tract disease using the SEER-Medicare database and evaluated quality of care in this space using a novel and easily applied metric. Less than half of patients met quality care criteria. Those that did meet criteria experienced longer overall survival at marginally increased costs. Background: Population-based studies evaluating outcomes for metastatic upper tract urothelial carcinoma (mUTUC) are sparse and rarely capture both patients with de novo (synchronous) metastases and those who progress to metastatic disease (metachronous). Herein we evaluated the outcomes and costs associated with synchronous and metachronous mUTUC, utilizing a novel Methodology. Additionally, we created a guideline-based quality score to improve care in this space. Patients and Methods: We identified all patients with mUTUC aged 66 years and older included in the SEER-Medicare linked database between 2004 and 2012. Achievement of 3 quality cr iter ia was assessed: (1) cancer-specific survival (CSS) > 12 months; (2) receipt of systemic therapy; (3) receipt of hospice/palliative care. Total healthcare and out-of-pocket costs were evaluated. Regression analyses were performed to assess characteristics associated with quality criteria and total healthcare costs. Results: Of the 1223 patients identified, at least one quality cr iter ion was met in just 40.2% and only 54 patients (4.4%) received palliative care. In multivariable analysis, patients with synchronous mUTUC (OR:0.55, 95%CI:0.41-0.72), and at least 3 comorbidities (OR:0.68, 95%CI:0.47-0.98) were less likely to achieve at least 1 quality cr iter ion. Meeting at least 1 quality cr iter ion was associated with increased costs ($94,677, 95%CI:87,702-101,652 versus $63,575, 95%CI:59,598-67,552). Conclusions: Less than half of patients with mUTUC met at least 1 quality cr iter ion. Quality score achievement was associated with a modest increase in total healthcare spending. These findings not only provide guidance for future study of rare diseases using secondary data, but also highlight inadequacies in the current management of mUTUC. [ABSTRACT FROM AUTHOR]

Purpose: The diagnostic accuracy of computed tomography urography for upper tract urothelial carcinoma is high; however, difficulties are associated with precisely assessing the T stage. Preoperative tumor staging has an impact on treatment options for upper tract urothelial carcinoma. We herein attempted to identify preoperative factors that predict pathological tumor up-staging, which will facilitate the selection of treatment strategies. Materials and methods: We retrospectively identified 148 patients with upper tract urothelial carcinoma who underwent computed tomography urography preoperatively followed by radical nephroureterectomy without preoperative chemotherapy at our institution between 2000 and 2021. Preoperative factors associated with cT2 or lower to pT3 up-staging were examined using a multivariate logistic regression analysis. Results: Ninety out of 148 patients were diagnosed with cT2 or lower, and 22 (24%) were up-staged to pT3. A multivariate analysis identified a positive voided urine cytology (HR 4.69, p = 0.023) and tumor length ≥ 3 cm (HR 6.33, p = 0.003) as independent predictors of pathological tumor up-staging. Conclusions: Patients diagnosed with cT2 or lower, but with preoperative positive voided urine cytology and/or tumor diameter ≥ 3 cm need to be considered for treatment as cT3. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate predictive factors of increasing intravesical recurrence (IVR) rate in patients with upper tract urothelial carcinoma (UTUC) after receiving radical nephroureterectomy (RNUx) with bladder cuff excision (BCE). Materials and methods: A total of 2114 patients were included from the updated data of the Taiwan UTUC Collaboration Group. It was divided into two groups: IVR-free and IVR after RNUx, with 1527 and 587 patients, respectively. To determine the factors affecting IVR, TNM stage, the usage of pre-operative ureteroscopy, and pathological outcomes were evaluated. The Kaplan–Meier estimator was used to estimate the rates of prognostic outcomes in overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS), and the survival curves were compared using the stratified log-rank test. Results: Based on our research, ureter tumor, female, smoking history, age (< 70 years old), multifocal tumor, history of bladder cancer were determined to increase the risk of IVR after univariate analysis. The multivariable analysis revealed that female (BRFS for male: HR 0.566, 95% CI 0.469–0.681, p < 0.001), ureter tumor (BRFS: HR 1.359, 95% CI 1.133–1.631, p = 0.001), multifocal (BRFS: HR 1.200, 95% CI 1.001–1.439, p = 0.049), history of bladder cancer (BRFS: HR 1.480, 95% CI 1.118–1.959, p = 0.006) were the prognostic factors for IVR. Patients who ever received ureterorenoscopy (URS) did not increase the risk of IVR. Conclusion: Patients with ureter tumor and previous bladder UC history are important factors to increase the risk of IVR after RNUx. Pre-operative URS manipulation is not associated with higher risk of IVR and diagnostic URS is feasible especially for insufficient information of image study. More frequent surveillance regimen may be needed for these patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with nonmetastatic UTUC. METHODS: We identified 4114 patients diagnosed with nonmetastatic UTUC from 2004 to 2013 in the Survival Epidemiology, and End Results-Medicare population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided. RESULTS: After risk stratification, 1027 (24.9%) and 3087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least 1 surgical intervention (95.1%); 68.4% underwent at least 1 endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%; P

Background: Endoscopic management of upper tract urothelial cancer (UTUC) is an important treatment option for low risk UTUC. Although Taiwan is an endemic area for UTUC, endoscopic treatment outcomes in Taiwan are frequently under- reported. Methods: This study retrospectively reviewed the treatment outcomes of endoscopic management for clinically localized UTUC. Patients with biopsy or washing cytology confirmed UTUC who underwent endoscopic or percutaneous management with a curative intent were retrospectively reviewed for eligibility of analysis. Those cases without pre-intervention confirmed UTUC, and metastatic or nodal disease at diagnosis were excluded. Results: In total, 307 patients who underwent endoscopic management were reviewed and 279 cases were eligible for final analysis. With a median follow-up of 44.3 months (inter-quartile range (IQR): 23.4–76.4 months), 117 cases (46.4%) were endoscopic cured after median one session (range:1–8; IQR:1–2) of endoscopic treatment. Those endoscopic cured UTUC was associated with more small-sized tumor, more low-grade biopsied-histology, less concomitant bladder UC and less pre-operative hydronephrosis.In addition, 201(79.7%) cases among 252 cases with confirmed oncological outcome were free of UTUC at the end of follow-up and only 43 (17%) patients had a UTUC related mortality. Salvage RNU offered a better tumor free survival rate (92% vs. 77.5%) than those without salvage RNU in those UTUC refractory to endoscopic management. In multivariable analyses, pre-operative hydronephrosis was the independent risk factor for OS. Multiplicity and concomitant bladder UC were independent risk factors for DFS. Conclusions: We confirmed the consistent safety and efficacy of endoscopic management of clinical localized UTUC in a highly UTUC endemic area like Taiwan. Early salvage RNU is mandatory in those UTUC refractory to endoscopic management in prevention of UTUC related death.

ABSTRACT Purpose: To compare the effects of different combinations of radical nephroureterectomy (RNU) and bladder cuff excision (BCE) surgical procedures on intravesical recurrence (IVR) in patients with upper tract urothelial carcinoma (UTUC). Materials and Methods: This retrospective observational study included 452 patients who underwent RNU with BCE for UTUC between January 2010 and December 2020. The patients were classified into three groups based on different combinations of RNU and BCE surgical procedures: open RNU with open BCE (group 1, n=104), minimally invasive (MIS) RNU with open BCE (group 2, n=196), and MIS RNU with intracorporeal BCE (group 3, n=152). Data on demographics, body mass index, history, preoperative renal function, perioperative status, tumor characteristics, histopathology, and recurrence conditions were collected. Multivariate Cox regression analyses were performed to determine the impact of the surgical procedures on IVR. P-values

Purpose This study aims to evaluate the systemic inflammatory response indices (SII) for the prediction of the non–organ-confined (non-OC) disease in upper urinary tract urothelial carcinoma (UTUC) patients. Materials and Methods From March 2010 to March 2020, patients who underwent radical nephroureterectomy (RNU) in a single tertiary center were retrospectively reviewed. Tumor location, multifocality, hydronephrosis on preoperative imaging, and preoperative SII, including C-reactive protein-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio (PLR) were used for analysis. Non-OC defined by locally advanced (pT3-4) or node-positive disease (pN1-2) in pathologic examination. Multivariable logistic regression was used for determining independent predictive markers of non-OC disease. Factors associated with locally advanced (pT3-4), and node-positive (pN1-2) disease were also analyzed. Results Overall, 711 UTUC patients who underwent RNU, without neoadjuvant chemotherapy, were analyzed. The average age was 68.6±9.9 years and 507 patients were male. Non-OC disease was 36.8% (262 of 711); specifically, 35.9% (255 of 711) was locally advanced and 7.2% (51 of 771) was node-positive disease. Multivariable analysis demonstrated hydronephrosis (odds ratio [OR], 1.46; 95%confidence interval [CI], 1.06–2.01; p=0.02), high PLR (OR, 1.45; 95% CI, 1.05–2.01; p=0.03), and high CAR (OR, 2.56; 95% CI, 1.79–3.66; p

Abstract Background To investigate the impact of Perirenal fat stranding (PRFS) on progression after radical nephroureterectomy (RNU) for renal pelvic urothelial carcinoma (RPUC) without hydronephrosis and to reveal the pathological findings of PRFS. Methods Clinicopathological data, including computed tomography (CT) findings of the ipsilateral PRFS, were collected from the medical records of 56 patients treated with RNU for RPUC without hydronephrosis between 2011 and 2021 at our institution. PRFS on CT was classified as either low or high PRFS. The impact of PRFS on progression-free survival (PFS) after RNU was analyzed using the Kaplan–Meier method and log-rank test. In addition, specimens including sufficient perirenal fat from patients with low and with high PRFS were pathologically analyzed. Immunohistochemical analysis of CD68, CD163, CD3, and CD20 was also performed. Results Of the 56 patients, 31(55.4%) and 25 (44.6%) patients were classified as having low and high PRFS, respectively. Within a median follow-up of 40.6 months postoperatively, 11 (19.6%) patients showed disease progression. The Kaplan–Meier method and log-rank test revealed that patients with high PRFS had significantly lower PFS rates than those with low PRFS (3-year PFS 69.8% vs 93.3%; p = 0.0393). Pathological analysis revealed that high PRFS specimens (n = 3 patients) contained more fibrous strictures in perirenal fat than low PRFS specimens (n = 3 patients). In addition, M2 macrophages (CD163 +) infiltrating fibrous tissue in perirenal area were observed in all patients with high PRFS group. Conclusions PRFS of RPUC without hydronephrosis consists of collagenous fibers with M2 macrophages. The presence of ipsilateral high PRFS might be a preoperative risk factor for progression after RNU for RPUC patients without hydronephrosis. Prospective studies with large cohorts are required in the future.

Purpose: To investigate the feasibility and optimal port placements of robot-assisted laparoscopic nephroureterectomy (RANU) via the retroperitoneal approach in the lateral decubitus and supine positions using the da Vinci Xi (DVXi) and da Vinci SP (DVSP) systems. Materials and Methods: We performed lateral decubitus extraperitoneal RANU on the right side and supine extraperitoneal RANU on the left side using the DVXi and DVSP systems without repositioning in two fresh cadavers. In addition, paracaval and pelvic lymphadenectomies were performed simultaneously during both surgical procedures. The operative time of each procedure was calculated, and the technical details associated with these procedures were evaluated. Results: Lateral decubitus and supine extraperitoneal RANU using the DVXi and DVSP systems were achieved without repositioning. The surgeon console time ranged from 89 to 178 minutes, and no major technical complications were observed. However, carbon dioxide insufflation into the abdominal cavity was observed owing to a peritoneal breach during the creation of the surgical workspace, particularly in the supine position. Compared with the DVXi system, the DVSP system was more suitable for RANU using the retroperitoneal approach, except for renal handling. Conclusions: The DVXi and DVSP systems are feasible for performing lateral decubitus and supine extraperitoneal RANU without patient repositioning. The lateral decubitus position may be better than the supine position, and the DVSP system is more suitable for retroperitoneal RANU than the DVXi system. Nevertheless, further studies should be performed in clinical settings to validate our results.

OBJECTIVE: To assess the differential response to neoadjuvant chemotherapy (NAC) in patients with urothelial carcinoma of the bladder (UCB) compared to upper tract urothelial carcioma (UTUC) treated with radical surgery. PATIENTS AND METHODS: Data from 1299 patients with UCB and 276 with UTUC were obtained from multicentric collaborations. The association of disease location (UCB vs UTUC) with pathological complete response (pCR, defined as a post-treatment pathological stage ypT0N0) and pathological objective response (pOR, defined as ypT0-Ta-Tis-T1N0) after NAC was evaluated using logistic regression analyses. The association with overall (OS) and cancer-specific survival (CSS) was evaluated using Cox regression analyses. RESULTS: A pCR was found in 250 (19.2%) patients with UCB and in 23 (8.3%) with UTUC (P

Purpose: The impact of body mass index (BMI) on patients with upper urinary tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU) is controversial. Increasing evidence suggests an age-dependent relationship between obesity and outcomes for some solid organ tumors. Herein, we aimed to assess the prognostic value of preoperative BMI in UTUC patients treated with RNU in Taiwan. Methods: This was a retrospective single-center study of 468 UTUC patients undergoing RNU during January 2010–December 2017, with preoperative BMI classification and subgroup analysis based on ages of < or ≥ 70 years. All UTUC patients underwent RNU and bladder cuff excision. Overall survival (OS), cancer-specific survival, and disease-free survival (DFS) were analyzed. Fisher's exact test, Mann–Whitney U test, Kaplan–Meier method, and Cox regression model were used for data analysis. Results: The median follow-up duration was 36 months. Patients with higher versus lower BMI (cutoff: 25 kg/m2) showed no differences in OS; older patients had poor OS (hazard ratio [HR] 1.74; 95% confidence interval [CI] 1.24–2.40; p < 0.001). Older age was an independent predictor of poor OS in multivariate Cox regression analysis (p = 0.001). Younger patients with higher BMI (p = 0.02) had better DFS than older patients with no BMI-related survival differences. Higher BMI was an independent predictor of favorable DFS in younger patients in multivariate Cox regression analysis (HR, 0.53; 95% CI 0.28–0.99; p = 0.043). Conclusion: Younger UTUC patients with higher BMI were independently associated with a favorable DFS. [ABSTRACT FROM AUTHOR]