Gautier Marcq, Beat Foerster, Mohammad Abufaraj, Surena F Matin, Mounsif Azizi, Mohit Gupta, Wei-Ming Li, Thomas Seisen, Timothy Clinton, Evanguelos Xylinas, M Carmen Mir, Donald Schweitzer, Andrea Mari, Shoji Kimura, Marco Bandini, Romain Mathieu, Ja H Ku, Georgi Guruli, Markus Grabbert, Anna K Czech, Tim Muilwijk, Armin Pycha, David D'Andrea, Firas G Petros, Philippe E Spiess, Trinity Bivalacqua, Wen-Jeng Wu, Morgan Rouprêt, Laura-Maria Krabbe, Kees Hendricksen, Shin Egawa, Alberto Briganti, Marco Moschini, Vivien Graffeille, Riccardo Autorino, Patricia John, Axel Heidenreich, Piotr Chlosta, Steven Joniau, Francesco Soria, Phillip M Pierorazio, Shahrokh F Shariat, Wassim Kassouf,
<h4>Background</h4>The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories.<h4>Objective</h4>To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS).<h4>Design, setting, and participants</h4>This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017.<h4>Outcome measurements and statistical analysis</h4>A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points.<h4>Results and limitations</h4>A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU).<h4>Conclusions</h4>Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design.<h4>Patient summary</h4>We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.
Eur Urol Focus (European urology focus)
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