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Journal of Peking University (Health Sciences) ›› 2026, Vol. 58 ›› Issue (4): 808-817. doi: 10.19723/j.issn.1671-167X.2026.04.018

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Comparison of preoperative nutritional scoring systems for predicting survival in upper tract urothelial carcinoma

Zejing GUO1, Changhai SUN1,2, Shicong LAI1, Hanlin GAO1, Yiqing DU1,*(), Tao XU1   

  1. 1. Department of Urology, Peking University People's Hospital, Beijing 100044, China
    2. Department of Urology, Peking University People's Hospital Qingdao Hospital, Qingdao University Affiliated Women and Children's Hospital, Qingdao 266034, Shandong, China
  • Received:2026-02-27 Online:2026-08-18 Published:2026-05-27
  • Contact: Yiqing DU
  • Supported by:
    the Noncommunicable Chronic Diseases-National Science and Technology Major Project(2024ZD0525700); the National Natural Science Foundation of China(82471866); the National Natural Science Foundation of China(82472912); the Beijing Natural Science Foundation(L252190)

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Abstract:

Objective: To investigate the association between preoperative nutritional indicators and survival outcomes in patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU), and to compare the predictive performance of different nutritional scoring systems. Methods: A retrospective analysis was conducted on UTUC patients who underwent RNU. Nutritional scores [geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), controlling nutritional status (CONUT), triglycerides-total cholesterol-body weight index (TCBI)] were calculated. Variables with P < 0.10 in univariable Cox regression were entered into multivariable analysis using backward stepwise selection based on the Akaike Information Criterion (AIC) to identify independent predictors and construct a nomogram. Kaplan-Meier curves with log-rank tests and time-dependent ROC curves were applied for survival analysis. A two-sided P < 0.05 was considered statistically significant. Results: A total of 481 UTUC patients were included. Multivariable analysis identified pathological T3/T4 stage, N1/N2 stage, high World Health Organization/International Society of Urological Pathology (WHO/ISUP) grade, estimated glomerular filtration rate (eGFR), blood transfusion, ureteral management, GNRI, and PNI as independent predictors of overall survival (OS) (P < 0.05). Independent predictors of cancer-specific survival (CSS) included pathological T2-T4 stage, N1/N2 stage, laparoscopic surgical approach, blood transfusion, GNRI, and PNI (P < 0.05). The nomogram constructed based on these independent predictors demonstrated good calibration. Patients with GNRI < 98 or PNI < 52 had significantly shorter OS and CSS (Log-rank P < 0.05). At the end of 60 months, the area under the curve (AUC) values of GNRI and PNI for predicting OS were 0.623 and 0.632, respectively, and for predicting CSS were 0.632 and 0.645, respectively. Time-dependent ROC analysis showed that both indicators had stable predictive performance for CSS, while their predictive ability for OS showed a mild increasing trend over the follow-up time. Conclusion: Preoperative GNRI and PNI are independently associated with OS and CSS in patients with UTUC after RNU, demonstrating stable predictive performance across different follow-up periods.

Key words: Upper tract urothelial carcinoma, Preoperative nutrition, Overall survival, Cancer-specific survival

CLC Number: 

  • R737.1

Table 1

Clinical characteristics of patients with UTUC"

Indicator Total (n=481)
Age/years 66.55±9.78
Gender
  Male 248 (51.6)
  Female 233 (48.4)
Smoking 73 (15.2)
Previous bladder cancer 30 (6.2)
Concomitant bladder cancer 41 (8.5)
T
  Ta/T1 119 (24.7)
  T2 121 (25.2)
  T3/T4 241 (50.1)
N
  Nx/N0 464 (96.5)
  N1/N2 17 (3.5)
Location
  Ureter 192 (39.9)
  Renal pelvis 227 (47.2)
  Ureter + Renal pelvis 62 (12.9)
Multifocality 112 (23.3)
WHO/ISUP grade
  Low grade 86 (17.9)
  High grade 395 (82.1)
eGFR/[mL/(min·1.73 m2)] 64.44±25.42
Surgical approach
  Open 39 (8.1)
  Laparoscopic 442 (91.9)
Surgical access
  Transabdominal 80 (16.6)
  Retroperitoneal 401 (83.4)
Distal ureter management
  Total laparoscopic 129 (26.8)
  Bladder opening 321 (66.7)
  Endoscopic-assisted 31 (6.4)
Lymph node dissection 88 (18.3)
Intravesical instillation 31 (6.4)
Blood transfusion 96 (20.0)

Table 2

Univariate and multivariate Cox analysis of factors influencing OS after UTUC surgery"

Variable Univariate analysis Multivariate analysis
HR 95%CI P HR 95%CI P
Age/years 1.027 1.010-1.044 0.002 1.008 0.990-1.026 0.401
Gendera
  Male Reference
  Female 0.863 0.636-1.172 0.346
Smoking index (cigarettes·years) 1.000 0.999-1.000 0.334
Previous bladder cancera 1.779 1.045-3.026 0.034 1.396 0.806-2.420 0.234
Concomitant bladder cancera 1.552 0.951-2.533 0.079 1.180 0.712-1.958 0.520
Ta
  Ta/T1 Reference
  T2 2.250 1.235-4.102 0.008 1.681 0.908-3.112 0.098
  T3/T4 4.906 2.907-8.278 < 0.001 3.716 2.166-6.374 < 0.001
Na
  Nx/N0 Reference
  N1/N2 3.298 1.783-6.098 < 0.001 2.003 1.071-3.748 0.030
Locationa
  Renal pelvis Reference
  Ureter 1.022 0.734-1.422 0.899
  Ureter + renal pelvis 0.999 0.615-1.622 0.997
Multiple vs. singlea 0.967 0.669-1.396 0.857
WHO/ISUP gradea
  Low grade Reference
  High grade 2.399 1.467-3.923 < 0.001 1.827 1.095-3.046 0.021
eGFR/[mL/(min·1.73 m2)] 0.985 0.978-0.991 < 0.001 0.993 0.986-1.000 0.038
Surgical approacha
  Open Reference
  Laparoscopic 0.571 0.363-0.898 0.015 0.687 0.431-1.096 0.115
Surgical accessa
  Transabdominal Reference
  Retroperitoneal 0.932 0.608-1.429 0.748
Distal ureter managementa
  Total laparoscopic Reference
  Bladder opening 0.479 0.348-0.660 < 0.001 0.574 0.412-0.798 < 0.001
  Endoscopic-assisted 0.431 0.214-0.867 0.018 0.465 0.228-0.950 0.036
Lymph node dissectiona 0.983 0.640-1.509 0.937
Intravesical instillationa 0.992 0.538-1.831 0.980
Blood transfusiona 2.117 1.521-2.948 < 0.001 1.807 1.275-2.562 < 0.001
GNRI 0.969 0.953-0.985 < 0.001 0.979 0.963-0.996 0.017
PNI 0.946 0.921-0.972 < 0.001 0.969 0.941-0.997 0.032
CONUT 1.145 1.028-1.274 0.014 1.045 0.932-1.171 0.453
TCBI 1.000 0.999-1.001 0.899

Table 3

Univariate and multivariate Cox analysis of factors influencing CSS after UTUC surgery"

Variable Univariate analysis Multivariate analysis
HR 95%CI P HR 95%CI P
Age/years 1.009 0.989-1.030 0.376
Gendera
  Male Reference
  Female 0.806 0.541-1.200 0.288
Smoking index (cigarettes×years) 0.999 0.998-1.000 0.081 0.999 0.998-1.000 0.104
Previous bladder cancera 1.132 0.495-2.585 0.769
Concomitant bladder cancera 1.730 0.945-3.166 0.075 1.294 0.690-2.426 0.422
Ta
  Ta/T1 Reference
  T2 6.232 1.826-21.266 0.003 4.159 1.194-14.484 0.025
  T3/T4 16.667 5.259-52.828 < 0.001 11.988 3.708-38.759 < 0.001
Na
  Nx/N0 Reference
  N1/N2 4.867 2.523-9.386 < 0.001 2.986 1.530-5.826 0.001
Locationa
  Renal pelvis Reference
  Ureter 1.184 0.770-1.822 0.441
  Ureter+renal pelvis 1.142 0.613-2.128 0.676
Multiple vs. singlea 1.137 0.722-1.791 0.580
WHO/ISUP gradea
  Low grade Reference
  High grade 3.554 1.644-7.682 0.001 1.838 0.831-4.063 0.133
eGFR/[mL/(min·1.73 m2)] 0.988 0.980-0.996 0.005 0.999 0.989-1.009 0.837
Surgical approacha
  Open Reference
  Laparoscopic 0.475 0.269-0.839 0.010 0.515 0.287-0.925 0.026
Surgical accessa
  Transabdominal Reference
  Retroperitoneal 0.637 0.392-1.034 0.068 0.901 0.529-1.534 0.700
Distal ureter managementa
  Total laparoscopic Reference
  Bladder opening 0.509 0.334-0.777 0.002 0.646 0.416-1.005 0.053
  Endoscopic-assisted 0.672 0.299-1.510 0.335 0.789 0.341-1.824 0.579
Lymph node dissectiona 1.323 0.807-2.168 0.267
Intravesical instillationa 0.913 0.400-2.087 0.829
Blood transfusiona 2.024 1.309-3.131 0.002 1.835 1.169-2.880 0.008
GNRI 0.966 0.946-0.987 0.002 0.971 0.950-0.991 0.005
PNI 0.946 0.913-0.980 0.002 0.959 0.924-0.995 0.025
CONUT 1.165 1.017-1.335 0.027 1.122 0.974-1.292 0.110
TCBI 1.000 0.998-1.001 0.511

Figure 1

ROC curves of GNRI and PNI in predicting OS (A) and CSS (B) survival at 60 months GNRI, geriatric nutritional risk index; PNI, prognostic nutritional index; OS, overall survival; CSS, cancer-specific survival; ROC, receiver operating characteristic; AUC, area under the curve."

Figure 2

Kaplan-Meier survival curves for GNRI (A, B) and PNI (C, D) dichotomization, truncated when risk set size < 10 GNRI, geriatric nutritional risk index; PNI, prognostic nutritional index."

Figure 3

Time-dependent AUC curves for GNRI (A, C) and PNI (B, D) predicting survival, with stage peak AUC values marked GNRI, geriatric nutritional risk index; PNI, prognostic nutritional index; OS, overall survival; CSS, cancer-specific survival; AUC, area under the curve."

Figure 4

Nomograms for GNRI predicting OS (A), PNI predicting OS (B), GNRI predicting CSS (C) and PNI predicting CSS (D) GNRI, geriatric nutritional risk index; PNI, prognostic nutritional index; OS, overall survival; CSS, cancer-specific survival; pT, pathological tumor stage; pN, pathological node stage; WHO/ISUP, World Health Organization/International Society of Urological Pathology; eGFR, estimated glomerular filtration rate; LG, low grade; HG, high grade."

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