Impact of prior endoscopic management of upper tract urothelial carcinoma on nephroureterectomy complexity.

PURPOSE: Kidney-sparing endoscopic surgery is considered the preferred approach for the treatment of low-risk upper tract urothelial cancer (UTUC), yet its impact on subsequent radical nephroureterectomy's (RNU) surgical complexity remains uncertain. This study aims to evaluate the effect of prior endoscopic procedures on peri-operative outcomes of UTUC patients undergoing RNU.

METHODS

A retrospective analysis of 176 consecutive UTUC patients who underwent RNU from July 2008 to July 2023 at a single tertiary center. Demographic, clinical, and pathological data were recorded. The cohort was stratified based on the intention of endoscopic intervention: patients who did not undergo ureteroscopy and those who underwent a single diagnostic ureteroscopy only (non-mURS group) were compared to those who underwent multiple endoscopic treatments with laser ablation as part of a kidney-sparing strategy before RNU referral (mURS group). Statistical analyses addressed the correlations between ureteroscopy frequency and surgical complexity. Multivariate regression analysis was conducted to assess surgical complexity.

RESULTS

Among 176 patients who underwent RNU, 63 (35.7%) were included in the mURS group, and 113 (64.3%) in the non-mURS group. The mURS patients had longer RNU duration (306 ± 114 vs. 269 ± 114 min, p = 0.005), greater blood loss (hemoglobin decrease of 3.5 ± 1.1 vs. 1.02 ± 0.49 g/dL, p < 0.001), increased peri-ureteral adhesions (88.9% vs. 25.7%, p < 0.001), higher postoperative opioid use (87% vs. 53%, p < 0.001), and higher prevalence of fibrosis in pathology reports (88.9% vs. 30.9%, p < 0.001). No significant differences were found in post-operative complications.

CONCLUSION

Pre-RNU endoscopic treatment for UTUC is associated with increased surgical complexity of RNU without adversely affecting postoperative complication rates.