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Journal of Peking University(Health Sciences) ›› 2019, Vol. 51 ›› Issue (4): 665-672. doi: 10.19723/j.issn.1671-167X.2019.04.012

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Impact of diagnostic ureteroscopy and biopsy on radical nephroureterectomy of upper tract urothelial carcinoma

Run-zhuo MA1,Hai-zhui XIA1,Min LU2,Zhi-ying ZHANG1,Qi-ming ZHANG1,Jian LU1,Guo-liang WANG1,△(),Lu-lin MA1,△()   

  1. 1. Department of Urology, Peking University Third Hospital, Beijing 100191, China
    2. Department of Pathology, Peking University Third Hospital, Beijing 100191, China
  • Received:2019-03-15 Online:2019-08-18 Published:2019-09-03
  • Contact: Guo-liang WANG,Lu-lin MA E-mail:wangguoliang@medmail.com.cn;malulinpku@163.com

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Abstract:

Objective: To investigate the impact of preoperative diagnostic ureteroscopy and biopsy (UB) on radical nephroureterectomy (RNU) and the prognosis of upper tract urothelial carcinoma (UTUC).Methods: The clinical data of UTUC patients receiving RNU between Jan. 2007 and Dec. 2016 were retrospectively collected. The median follow up time was 40 months. The operation time and blood loss of RNU were compared between UB group and non-UB group. Subgroup analyses were conducted according to the time interval between UB and RNU, and surgery methods of lower ureter. The linear regression model was used to adjust for other common factors that impacted operation time.Results: A total of 163 UTUC patients were included in the final analysis. For the lower ureter, open ureterectomies were performed in 91 patients (55.9%), while retroperitoneal laparoscopic ureterectomies were performed in 72 patients (44.1%). A total of 110 (67.5%) patients received preoperative UB. Compared with non-UB group, the average operation time of UB group was significantly longer [(252.5±79.8) min vs. (221.3±79.8) min, P=0.019], but no difference of blood loss was found (median, 50 mL vs. 50 mL, P=0.143). In subgroup analysis, the average operation time of RNU was significantly prolonged when RNU was performed after 1 week of UB (P=0.023). Meanwhile, the median blood loss of RNU increased significantly when it was done after 2 weeks of UB compared with non-UB group (100 mL vs. 50 mL, P=0.012). UB was also significantly prolonged the operation time of RNU in retroperitoneal laparoscopic ureterectomy group (P=0.012). In multivariable analysis, UB (P=0.049), ≥pT3 (P=0.039), pN+ (P=0.018) and ureterectomy method (P=0.005) were independent risk factors of prolonged operation time. The 3-year cancer specific survival (CSS) rate was 87.2% in our cohort. UB had no significant impact on cancer specific survival (P=0.435).Conclusion: UB was an independent risk factor of prolonged RNU time, but did not significantly influence cancer specific survival of upper tract urothelial carcinoma patients.

Key words: Ureteral Neoplasms, Ureteroscopy, Upper tract urothelial carcinoma, Retroperitoneal laparoscopic surgery

CLC Number: 

  • R737.1

Table 1

The clinical characteristics of 163 UTUC patients"

Characteristics Total (n=163) UB group (n=110) Non-UB group (n=53) P value
Gender (male/female) 71/92 51/59 20/33 0.298
Age/years, x?±s 67.0±10.4 66.1±10.7 69.0±9.7 0.099
BMI/(kg/m2), x?±s 24.5±3.3 24.3±2.9 (n=105) 25.1±3.9(n=49) 0.190
ASA score (n=162), n (%) 0.768
1 25 (16.2) 18 (17.1) 7 (14.3)
2 103 (66.9) 70 (66.7) 33 (67.3)
3 26 (16.9) 17 (16.2) 9 (18.4)
Surgery year, n (%) 0.542
2007-2011 45 (27.6) 32 (29.1) 13 (24.5)
2012-2016 118 (72.4) 78 (70.9) 40 (75.5)
Gross hematuria, n (%) 119 (73.0) 83 (75.5) 36 (67.9) 0.310
Bladder cancer history, n (%) 5 (3.1) 5 (4.5) 0 0.115
Smoking history, n (%) 17 (10.4) 13 (11.8) 4 (7.5) 0.403
eGFR/[mL/(min·1.73 m2)], x?±s 61.3±23.3 64.8±21.3 54.0±25.7 0.005
Side (left/right) 76/87 55/55 21/32 0.213
Location, n (%) 0.175
Renal pelvis 73 (44.8) 46 (41.8) 27 (50.9)
Ureter 80 (49.1) 59 (53.6) 21 (39.6)
Both 10 (6.1) 5 (4.2) 5 (9.4)
Tumor diameter/cm, median (min, max) 2.8 (0.5, 11.0) 2.5 (0.6, 11.0) 3.5 (0.5, 8.5) 0.228
Hydronephrosis (n=152), n (%) 83 (54.6) 62 (61.4) 21 (41.2) 0.018
Surgery method, n (%) 0.019
RPL+open 64 (39.3) 40 (36.4) 24 (45.3)
TUI+RPL+open 27 (16.6) 21 (19.1) 6 (11.3)
TUI+RPL 60 (36.8) 45 (40.9) 15 (28.3)
RPL 12 (7.4) 4 (3.6) 8 (15.1)
pT, n (%) 0.196
Ta 26 (16.0) 19 (17.3) 7 (13.2)
1 40 (24.5) 28 (25.5) 12 (22.6)
2 50 (30.7) 37 (33.6) 13 (24.5)
3 44 (27.0) 25 (22.7) 19 (35.8)
4 3 (1.8) 1 (0.9) 2 (3.8)
pN+, n (%) 5 (3.1) 3 (2.7) 2 (3.8) 0.717
High grade, n (%) 117 (71.8) 77 (70.0) 40 (75.5) 0.467
Multifocality, n (%) 22 (13.5) 13 (11.8) 9 (17.0) 0.366
Sessile, n (%) 26 (16.0) 19 (17.3) 7 (13.2) 0.507
Surgery duration/min, x?±s 242.3±79.8 252.5±79.8 221.3±79.8 0.019
Blood loss/mL, median (min, max) 50 (10, 1 000) 50 (10, 1 000) 50 (10, 800) 0.143

Figure 1

Impact of UB on RNU duration as per time interval between these two procedures *P<0.05; NS, non-significant; RNU, radical nephroureterectomy; UB, ureteroscopy and biopsy."

Table 2

The impact of UB on duration of RNU as per different procedures of distal ureter resection"

Procedures of distal ureter
(samples of each cohort)		 RPLRNU duration/min, x?±s P value
≥1 week
after UB		 Non-UB/<1 week
after UB
Open (55 vs. 36) 272.4±84.7 241.9±92.5 0.114
RPL (43 vs. 29) 233.5±60.3 198.9±48.8 0.012

Table 3

Multivariable analysis of factors relating to duration of RNU"

Clinical factors Duration of surgery
β 95%CI P value
Age -0.245 -1.379 to 0.889 0.670
Surgery after 2012 -12.781 -41.943 to 16.38 0.387
eGFR 0.508 -0.013 to 1.029 0.056
Side, right 3.666 -20.051 to 27.383 0.760
Location
Renal pelvis Ref. Ref. Ref.
Ureter 25.349 -3.722 to 54.421 0.087
Both 6.088 -45.051 to 57.226 0.816
Tumor diameter 2.863 -4.022 to 9.749 0.412
≥pT3 27.302 1.372 to 53.232 0.039
pN+ 78.689 13.510 to 143.868 0.018
Hydronephrosis 27.447 -1.488 to 56.382 0.063
Open dissection of distal ureter 34.554 10.456 to 58.653 0.005
After UB 27.186 0.176 to 54.197 0.049

Figure 2

The prognostic impact of UB on UTUC patients UTUC, upper tract urothelial carcinoma; UB, ureteroscopy and biopsy."

Table 4

Univariable analysis of prognostic factors in UTUC"

Items OS CSS PFS
HR 95%CI P value HR 95%CI P value HR 95%CI P value
Male 1.56 0.85-2.87 0.155 1.78 0.89-3.54 0.102 1.32 0.71-2.46 0.387
Age 1.01 0.98-1.04 0.514 1.02 0.99-1.06 0.219 1.01 0.98-1.05 0.385
ASA score 0.374 0.262 0.123
1 Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
2 0.59 0.28-1.25 0.166 0.51 0.23-1.15 0.105 0.51 0.25-1.04 0.064
3 0.76 0.29-1.99 0.571 0.71 0.25-2.01 0.522 0.42 0.14-1.20 0.104
Bladder cancer history 2.60 0.62-10.86 0.192 3.19 0.76-13.45 0.115 2.28 0.55-9.52 0.257
Smoking history 0.92 0.33-2.57 0.869 0.85 0.26-2.80 0.791 0.93 0.33-2.62 0.896
eGFR 1.00 0.98-1.01 0.586 0.99 0.98-1.01 0.418 1.00 0.99-1.01 0.882
Right side 0.90 0.49-1.63 0.717 0.55 0.27-1.10 0.093 0.60 0.32-1.11 0.105
Location 0.225 0.589 0.392
Renal pelvis Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Ureter 1.66 0.85-3.24 0.142 1.34 0.64-2.78 0.439 0.59 0.17-2.07 0.414
Both 2.25 0.73-6.94 0.157 1.80 0.51-6.40 0.365 0.93 0.28-3.09 0.900
Tumor diameter 1.34 1.17-1.52 <0.001 1.39 1.21-1.60 <0.001 1.32 1.16-1.50 <0.001
Muscle-invasiveness 2.97 1.46-6.04 0.003 3.89 1.60-9.43 0.003 4.04 1.78-9.14 0.001
pN+ 6.39 2.25-18.18 0.001 7.89 2.74-22.71 <0.001 8.40 2.95-23.93 <0.001
High grade 2.68 1.13-6.38 0.026 4.23 1.28-13.92 0.018 5.55 1.71-18.01 0.004
Multifocality 1.58 0.73-3.42 0.243 1.49 0.61-3.60 0.381 1.76 0.81-3.82 0.153
Hydronephrosis 2.49 1.19-5.20 0.015 2.06 0.94-4.51 0.070 2.69 1.31-5.55 0.007
Sessile 2.17 1.09-4.32 0.028 2.89 1.40-5.96 0.004 2.84 1.44-5.59 0.003
TUI 0.90 0.48-1.67 0.735 0.94 0.47-1.88 0.855 0.85 0.45-1.59 0.602
Preoperative UB 1.07 0.55-2.10 0.843 1.37 0.62-3.05 0.438 1.25 0.63-2.51 0.526

Table 5

Multivariable analysis of prognostic factors in UTUC"

Items OS CSS PFS
HR 95%CI P value HR 95%CI P value HR 95%CI P value
Location 0.334 0.397 0.804
Renal pelvis Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Ureter 0.85 0.20-3.60 0.826 1.71 0.33-8.95 0.523 1.57 0.39-6.34 0.525
Both 1.60 0.44-5.81 0.473 2.66 0.54-12.97 0.227 1.32 0.37-4.73 0.673
Tumor diameter 1.34 1.14-1.57 <0.001 1.43 1.20-1.71 <0.001 1.26 1.09-1.46 0.002
Muscle-invasiveness 2.53 1.00-6.40 0.050 2.27 0.76-6.72 0.140 2.61 1.05-6.49 0.040
pN+ 3.50 1.00-12.21 0.050 3.36 0.93-12.14 0.064 5.03 1.42-17.82 0.012
High grade 1.63 0.51- 5.21 0.413 2.80 0.58-13.55 0.200 4.94 1.11-21.94 0.036
Multifocality 1.52 0.60-3.90 0.381 1.37 0.47-3.96 0.563 1.75 0.70-4.36 0.229
Hydronephrosis 1.25 0.52-2.96 0.619 1.14 0.44-2.95 0.787 1.80 0.81-4.00 0.147
Sessile 1.44 0.62-3.35 0.400 1.79 0.71-4.54 0.218 0.92 0.41-2.05 0.839
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