EURURO Vol. 71 No. 4

E109 692

Letter to the Editor
Re: Thomas Seisen, Benoit Peyronnet, Jose Luis
Dominguez-Escrig, et al. Oncologic Outcomes of
Kidney-sparing Surgery Versus Radical
Nephroureterectomy for Upper Tract Urothelial
Carcinoma: A Systematic Review by the EAU
Non-muscle Invasive Bladder Cancer Guidelines Panel.
Eur Urol 2016;70:1052–68
Preoperative Bladder Cancer History and Chronic Kidney
Disease Are Associated with Occult Renal Pelvis Cancer in
Preoperative Solitary Ureteral Cancer
Seisen et al present a systemic review revealing similar
survival after kidney-sparing surgery (KSS) compared to
radical nephroureterectomy (RNU) only for low-grade and
noninvasive upper urinary tract urothelial carcinoma
(UTUC). However, selected patients with high-grade and
invasive UTUC could safely benefit from KSS when feasible.
Preoperative computed tomograpy (CT) imaging is routine-
ly performed before RNU for cancer staging. However, flat or
small lesions in the renal pelvis are difficult to detect. It has
been hypothesized that intraluminal cancer seeding can
cause UC recurrence . Occult renal pelvis UC (RPUC)
may be associated with continuous tumor cell shedding,
with possible seeding on the post-ureteroureterostomy
rough surface. KSS should be carefully performed in highly
selected patients with high-grade UTUC and minimal risk of
occult UTUC.
We performed a retrospective study to identify patients
with a risk of occult RPUC among patients with preoperative
UC in a solitary ureter. From 2005 to 2012, 263 patients with
preoperative UC in a solitary ureter underwent RNU at
Kaohsiung Chang Gung Medical Center . Preopera-
tive CT imaging was performed for all patients. Qualified
radiologists were blinded to the pathologic result and
oncologic outcome. Perioperative data, such as age, gender,
and UC risk factors including smoking history, bladder
cancer history, chronic kidney disease (CKD) stage classified
according to the glomerular filtration rate estimated via the
Modification of Diet in Renal Disease formula, and grade of
hydronephrosis, were obtained via chart review. Patholo-
gists at our institution recorded pathological features.
Patients were divided into two groups according to the
presence of occult RPUC. Perioperative data were recorded
via chart review. Multivariate binary logistic regression was
used to analyze the impact of risk factors for occult RPUC.
There were 38 patients (14%) with occult RPUC after RNU
in our series. Univariate analysis revealed that the incidence
of preoperative CKD stage >2 and bladder cancer history
was significantly higher among patients with occult RPUC
(p = 0.004 and 0.003, respectively; . Multivariate
analysis revealed that history of bladder cancer (odds ratio
[OR] 2.948, 95% confidence interval [CI] 1.378–6.308;
p = 0.005) and preoperative CKD stage >2 (OR 2.207, 95%
CI 1.067–4.565; p = 0.033) as independent risk factors for
occult RPUC.
CKD is common in patients with UTUC and was reported
to be associated with UTUC outcome because of some
common etiologic factors such as aristolochic acid and
ava ilable at
journal homepage:
Table 1 – Demographic data for patients with ureter tumor treated
with radical nephroureterectomy
Renal pelvis urothelial
carcinoma
p value
Positive
(n = 38)
Negative
(n = 225)
Follow-up duration
Gender, n (%) 0.054
Male 12 (32) 110 (49)
Female 26 (68) 115 (51)
Mean age (yr) 64.63 67.62 0.088
Preoperative CKD stage, n (%) 0.005
Stage I 0 11 (5)
Stage II 2 (5) 44 (20)
Stage III 14 (37) 95 (42)
Stage IV 5 (13) 31 (13)
Stage V 17 (45) 44 (20)
Smoking history, n (%) 5 (13) 41 (18) 0.447
Bladder cancer history, n (%) 16 (42) 45 (20) 0.003
Hydronephrosis, n (%) 0.533
Grade 2 14 (37) 72 (32)
> Grade 2 24 (63) 153 (68)
Pathology stage 5 (13) 51 (23) 0.185
T0–1
T2
T3–4
CKD = chronic kidney disease.
DOI of original article: .
0302-2838/# 2016 Published by Elsevier B.V. on behalf of European Association of Urology.