Clinicopathological Predictors of Survival After Radical Nephroureterectomy for UTUC: A Propensity Score-Matched Multicenter Analysis.

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) is characterized by heterogeneous outcomes and high recurrence risk. We aimed to identify independent predictors of survival and intravesical recurrence using a bias-adjusted statistical framework.

PATIENTS AND

METHODS

We retrospectively analyzed 503 patients undergoing radical nephroureterectomy (RNU). Beyond Multivariable Cox regression, propensity score matching (PSM) was used to evaluate the impact of adjuvant chemotherapy. Perioperative estimated glomerular filtration rate (eGFR) changes and cisplatin eligibility were quantified. Sensitivity analyses excluding NX patients and a 90-day landmark analysis were performed.

RESULTS

At a median follow-up of 31.6 months, estimated 3-year Overall Survival (OS), Cancer-Specific Survival, Disease-Free Survival (DFS), and Intravesical Recurrence-Free Survival were 75.8%, 91.5%, 73.1%, and 63.7%, respectively. Advanced pathologic stage (≥pT3), nodal involvement, and variant/squamous differentiation independently predicted mortality. Intravesical recurrence was associated with ureteral location, multifocality, carcinoma in situ, and diagnostic ureterorenoscopy. Postoperatively, 49.7% of patients had eGFR < 60 mL/min/1.73 m², and 35.4% of preoperatively eligible patients (preop eGFR ≥ 60, n = 336) experienced a decline below the cisplatin threshold. Following PSM (n = 222; 111 per arm), no statistically significant survival difference was observed for OS (hazard ratio [HR]: 1.31, 95% confidence intervals [CI]: 0.87-1.98; P = .199), CSS (HR: 1.50, P = .302), or DFS (HR: 1.36, P = .135), including in high-risk patients (≥pT3/pN+). Post-hoc power analysis confirmed the study was substantially underpowered to detect a clinically meaningful treatment effect (power < 37% for a 30% hazard reduction).

CONCLUSION

UTUC outcomes are primarily driven by tumor biology, while intravesical recurrence reflects multifocality and procedure-related factors. Postoperative renal decline was common following RNU, potentially limiting cisplatin candidacy in real-world practice. The present study was substantially underpowered and could neither confirm nor exclude a survival benefit from adjuvant chemotherapy; prospective evaluation of neoadjuvant strategies is warranted.