Email Alert | RSS

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

Previous Articles     Next Articles

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

RICH HTML

   

PDF (PC)

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
[1] Roupret M, Babjuk M, Comperat E , et al. European Association of Urology Guidelines onupper urinary tract urothelial carcinoma: 2017 update[J]. Eur Urol, 2018,73(1):111-122.
[2] Soria F, Shariat SF, Lerner SP , et al. Epidemiology, diagnosis, preoperative evaluation and prognostic assessment of upper-tract urothelial carcinoma (UTUC)[J]. World J Urol, 2017,35(3):379-387.
[3] Marchioni M, Primiceri G, Cindolo L , et al. Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a syste-matic review and meta-analysis[J]. BJU Int, 2017,120(3):313-319.
[4] Guo RQ, Hong P, Xiong GY , et al. Impact of ureteroscopy before radical nephroureterectomy for upper tract urothelial carcinomas ononcological outcomes: a meta-analysis[J]. BJU Int, 2018,121(2):184-193.
[5] Ma YC, Zuo L, Chen JH , et al. Modified glomerular filtration rate estimating equation for Chinese patients with chronic kidney disease[J]. J Am Soc Nephrol, 2006,17(10):2937-2944.
[6] Brierley JD . TNM classification of malignant tumors[M]. 8th ed. Wiley-Blackwell: UICC International Union Against Cancer, 2017.
[7] Eble J, Sauter G, Epstein J , et al. Pathology and genetics of tumours of the urinary system and male genital organs[J]. Histopathology, 2010,46(5):586.
[8] Moch H, Humphrey PA, Ulbright TM , et al. WHO classification of tumours of the urinary system and male genital organs[M]. 4th ed. France: Lyon, 2016.
[9] Tan P, Xie N, Yang L , et al. Diagnosticureteroscopy prior to radical nephroureterectomy for upper tract urothelial carcinoma increased the risk of intravesical recurrence[J]. Urol Int, 2018,100(1):92-99.
[10] Liu Z, Zheng S, Li X , et al. Oncologic outcomes of patients undergoing diagnostic ureteroscopy before radical nephroureterectomy for upper urinary tract urothelial carcinomas: a systematic review and meta-analysis[J]. J Laparoendosc Adv Surg Tech A, 2018,28(11):1316-1325.
[11] Lee HY, Yeh HC, Wu WJ , et al. The diagnostic ureteroscopy before radical nephroureterectomy in upper urinary tract urothelial carcinoma is not associated with higher intravesical recurrence[J]. World J Surg Oncol, 2018,16(1):135.
[12] Xylinas E, Kluth L, Passoni N , et al. Prediction of intravesical recurrence after radical nephroureterectomy: development of a clinical decision-making tool[J]. Eur Urol, 2014,65(3):650-658.
[13] Luo HL, Kang CH, Chen YT , et al. Diagnostic ureteroscopy independently correlates with intravesical recurrence after nephroureterectomy for upper urinary tracturothelial carcinoma[J]. Ann Surg Oncol, 2013,20(9):3121-3126.
[14] Lee JK, Kim KB, Park YH , et al. Correlation between the timing of diagnostic ureteroscopy and intravesical recurrence in upper tract urothelial cancer[J]. Clin Genitourin Cancer, 2016,14(1):e37-e41.
[15] Horuz R, Goktas C, Cetinel CA , et al. Simple preoperative parameters to assess technical difficulty during a radicalperineal prostatectomy[J]. Int Urol Nephrol, 2013,45(1):129-133.
[16] Liu P, Su XH, Xiong GY , et al. Diagnosticureteroscopy for upper tract urothelial carcinoma is independently associated with intrave-sical recurrence after radical nephroureterectomy[J]. Int Braz J Urol, 2016,42(6):1129-1135.
[17] Sankin A, Tin AL, Mano R , et al. Impact ofureteroscopy before nephroureterectomy for upper tract urothelial carcinoma on oncolo-gic outcomes[J]. Urology, 2016,94:148-153.
[18] Lee JN, Kwon SY, Choi GS , et al. Impact of surgical wait time on oncologic outcomes in upper urinary tracturothelial carcinoma[J]. J Surg Oncol, 2014,110(4):468-475.
[19] Waldert M, Karakiewicz PI, Raman JD , et al. A delay in radical nephroureterectomy can lead to upstaging[J]. BJU Int, 2010,105(6):812-817.
[20] Boorjian S, Ng C, Munver R , et al. Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma[J]. Uro-logy, 2005,66(2):283-287.
[21] Nison L, Roupret M, Bozzini G , et al. The oncologic impact of a delay between diagnosis and radicalnephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas: results from a large collaborative database[J]. World J Urol, 2013,31(1):69-76.
[22] Shibing Y, Liangren L, Qiang W , et al. Impact of tumour size on prognosis of upper urinary tract urothelial carcinoma after radical nephroureterectomy: a multi-institutional analysis of 795 cases[J]. BJU Int, 2016,118(6):902-910.
[23] Simone G, Papalia R, Loreto A , et al. Independent prognostic value of tumour diameter and tumour necrosis in upper urinary tracturothelial carcinoma[J]. BJU Int, 2009,103(8):1052-1057.
[24] Espiritu PN, Sverrisson EF, Sexton WJ , et al. Effect of tumor size on recurrence-free survival of upper tract urothelial carcinoma following surgical resection[J]. Urol Oncol, 2014,32(5):619-624.
[25] Pieras E, Frontera G, Ruiz X , et al. Concomitant carcinoma in situ and tumour size are prognostic factors for bladder recurrence after nephroureterectomy for upper tract transitional cell carcinoma[J]. BJU Int, 2010,106(9):1319-1323.
[26] Milenkovic-Petronic D, Milojevic B, Djokic M , et al. The impact of tumor size on outcomes in patients with upper urinary tracturothelial carcinoma[J]. Int Urol Nephrol, 2014,46(3):563-569.
[27] Su X, Fang D, Li X , et al. Theinfluence of tumor size on oncolo-gic outcomes for patients with upper tract urothelial carcinoma after radical nephroureterectomy[J]. Biomed Res Int, 2016,2016:4368943.
[1] Xiaoteng YU, Yixuan HUANG, Xinfei LI, Changfu CHEN, Fangzhou ZHAO, Honggang YING, Zihao TAO, Yiming ZHANG, Liqing XU, Zhihua LI, Kunlin YANG, Liqun ZHOU, Xuesong LI, Zheng ZHAO. Surgical techniques and clinical outcomes of upper urinary tract reconstruction for stone-related ureteral strictures [J]. Journal of Peking University (Health Sciences), 2025, 57(4): 670-675.
[2] Lei WANG,Tian-dong HAN,Wei-xing JIANG,Jun LI,Dao-xin ZHANG,Ye TIAN. Comparison of safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by flexible ure-teroscopy [J]. Journal of Peking University (Health Sciences), 2023, 55(3): 553-557.
[3] Zhi-hua LI,Chun-ru XU,Yin LIU,Hua GUAN,Meng ZHANG,Xin-yan CHE,Qi TANG,Yan-bo HUANG,Xue-song LI,Li-qun HOU. Correlation between daily fluid intake behavioral habits and pathological characteristics of upper tract urothelial carcinoma [J]. Journal of Peking University (Health Sciences), 2022, 54(4): 621-627.
[4] Xiang DAI,Fei WANG,Yi-qing DU,Yu-xuan SONG,Tao XU. Correlation between adipokine and clinicopathological features and prognosis in upper tract urothelial carcinoma [J]. Journal of Peking University (Health Sciences), 2022, 54(4): 605-614.
[5] CHEN Huai-an,LIU Shuo,LI Xiu-jun,WANG Zhe,ZHANG Chao,LI Feng-qi,MIAO Wen-long. Clinical value of inflammatory biomarkers in predicting prognosis of patients with ureteral urothelial carcinoma [J]. Journal of Peking University (Health Sciences), 2021, 53(2): 302-307.
[6] Bao GUAN,Mai WENG,Hang FAN,Ding PENG,Dong FANG,Geng-yan XIONG,Xue-song LI,Li-qun ZHOU. Evaluating the impact of preoperative anemia on the prognosis of upper tract urothelial carcinoma following radical nephroureterectomy: A single-center retrospective study of 686 patients [J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1056-1061.
[7] HAO Yi-chang, CHEN Kun, LIU Yu-qing, LU Jian, XIAO Chun-lei, MA Lu-lin. Transurethral flexible ureteroscopic holmium laser resection for tumors of renal pelvis: 6 cases report and literature review [J]. Journal of Peking University(Health Sciences), 2018, 50(5): 816-821.
[8] MA Run-zhuo, QIU Min, HE Wei, YANG Bin, XIA Hai-zhui, ZOU Da, LU Min, MA Lu-lin1, LU Jian. Ureteroscope can assist risk stratification in upper tract urothelial carcinoma [J]. Journal of Peking University(Health Sciences), 2017, 49(4): 632-637.
[9] YE Xiong-jun1, LIU Jun, Abudukeymu ABLIMIT,XIONG Liu-lin, LIU Shi-jun, XU Tao, HUANG Xiao-bo. Clinical application of retroperitoneal laparoscopic surgery combined with miniflank incision “hybrid surgery” for partial nephrectomy of complex renal tumors [J]. Journal of Peking University(Health Sciences), 2017, 49(4): 613-616.
[10] GUAN Bao, CAO Zhen-peng, PENG Ding, LI Yi-fan, ZHAN Yong-hao, LIU Li-bo, HE Shi-ming, XIONG Geng-yan, LI Xue-song, ZHOU Li-qun. Prognostic factors of patients with T2N0M0 upper tract urothelial carcinoma: a single-center retrospective study of 235 patients [J]. Journal of Peking University(Health Sciences), 2017, 49(4): 603-607.
[11] MA Kai, HUANG Xiao-Bo, XIONG Liu-Lin, XU Qing-Quan, XU Tao, YE Hai-Yun, YU Lu-Ping, WANG Xiao-Feng. Treatment of upper urinary calculi through novel modular flexible ureteroscope: a report of 36 cases [J]. Journal of Peking University(Health Sciences), 2015, 47(4): 615-617.
[12] ZHANG Li-Jie, YE Xiong-Jun, HUANG Xiao-Bo, XIONG Liu-Lin, MA Kai, LI Jian-Xing, WANG Xiao-Feng. Comparison of tubeless-percutaneous nephrolithotomy and ureteroscopic lithotripsy in treatment of upper-ureteral calculi sized ≥1.5 cm [J]. Journal of Peking University(Health Sciences), 2015, 47(1): 170-174.
[13] YANG Bo, HU Wei-Guo, HU Hao, CHEN Liang, LI Jian-Xing, WANG Xiao-Feng. Causes and remediations of retrograde intrarenal surgery failure in renal calculi treatment [J]. Journal of Peking University(Health Sciences), 2014, 46(5): 794-797.
Viewed
Full text


Abstract

Cited
  Shared   
  Discussed   
No Suggested Reading articles found!
Copyright © Journal of Peking University (Health Sciences), All Rights Reserved.
Powered by Beijing Magtech Co. Ltd