UROLOGICAL SURVEY
Urological Oncology
Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study
Lughezzani G, Sun M, Perrotte P, Shariat SF, Jeldres C, Budaus L, Alasker A, Duclos A, Widmer H, Latour M, Guazzoni G, Montorsi F, Karakiewicz PI
Cancer Prognosis and Health Outcomes Unit, University of Montreal Health Center, Montreal, Québec, Canada; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
Eur. Urol. 57: 956-962, 2010
Background: A large, multi-institutional, tertiary care center study suggested no benefit from bladder cuff excision (BCE) at nephroureterectomy in patients with upper tract urothelial carcinoma (UC).
Objective: We tested and quantified the prognostic impact of BCE at nephroureterectomy on cancer-specific mortality (CSM) in a large population-based cohort of patients with UC of the renal pelvis.
Design, Setting, and Participants: A cohort of 4210 patients with UC of the renal pelvis were treated with nephroureterectomy with (NUC) or without (NU) a BCE between 1988 and 2006 within 17 Surveillance, Epidemiology, and End Results registries.
Measurements: Cumulative incidence plots and competing risks regression models compared CSM after either NUC or NU. Covariates consisted of pathologic T and N stages, grade, age, year of surgery, gender, and race.
Results and Limitations: Respectively, 2492 (59.2%) and 1718 (40.8%) patients underwent a nephroureterectomy with or without BCE. In univariable and multivariable analyses, BCE omission increased CSM rates in patients with pT3N0/x, pT4N0/x, and pT(any)N1-3 UC of the renal pelvis. For example, in patients with pT3N0/x disease, holding all other variables constant, BCE omission increased CSM in a 1.25-fold fashion (p=0.04). Similarly, in patients with pT4N0/x disease, BCE omission resulted in a 1.45-fold increase (p=0.02). The main limitation of our study is the lack of data on disease recurrence.
Conclusions: Nephroureterectomy with BCE remains the standard of care in the treatment of UC of the renal pelvis and should invariably be performed in patients with locally advanced disease. Conversely, patients with pT1 and pT2 disease could be considered for NU without compromising CSM. However, recurrence data are needed to fully confirm the validity of this option.
Editorial Comment
Bladder cuff excision was regarded standard in all upper urinary tract urothelial tumors. Recently, however, this standard was challenged by reports that did not show any benefit from this procedure. Therefore, this large international, multi-institutional analysis from Canada, Italy and Germany including more than 4200 patients with urothelial cancer of the renal pelvis is very helpful in re-establishing the standard of care for this patient group.
Two important observations were made. First, in patients with positive lymph nodes, and in those with >pT2 tumors of the renal pelvis, cancer-specific mortality was significantly higher if bladder cuff excision (BCE) was omitted. Second, no survival benefit was seen in the group with smaller (pT1-2), node-negative tumors. Therefore, BCE may be omitted in select patients of this group.
A drawback of the study to my opinion was the lack of inclusion of ureteral cancers and I would hope that the authors will perform another analysis for this important subgroup, too. Still, these data re-establish the standard and strongly support routine BCE in cases with urothelial renal pelvis tumors.
Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de
Publication Dates
-
Publication in this collection
06 Dec 2010 -
Date of issue
Oct 2010
