EURURO Vol. 71 No. 4

E111 692

Letter to the Editor
Reply to Hao Lun Luo, Yen Ta Chen, Yuan Tso Cheng, and
Po Hui Chiang’s Letter to the Editor re: 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
The Key Role of Flexible Ureterorenoscopy in Kidney-
sparing Surgery for Upper Tract Urothelial Carcinoma
We read with interest the letter by Luo et al providing new
insights into patient selection for kidney-sparing surgery
(KSS) in the treatment of upper tract urothelial carcinoma
(UTUC). Using institutional data, the authors found that
chronic kidney disease and history of bladder cancer were
independent predictors of occult renal pelvis disease in
radical nephroureterectomy (RNU) patients preoperatively
diagnosed with solitary ureteral tumors. These results
suggest that KSS should be carefully considered for
individuals presenting with such baseline characteristics,
given the higher risk of residual disease after ureteroscopic
ablation (URS) or segmental ureterectomy (SU). However,
two major limitations may impact the findings of Luo et al.
First, from a methodological perspective, only the role of
preoperative characteristics such as clinical stage and
tumor grade on urinary cytology or biopsy should have
been assessed, as the ultimate goal is to identify indepen-
dent predictors for treatment decision-making before
undergoing surgery. In addition, the number of patients
eventually presenting with occult renal pelvis tumor was
too low to properly adjust for confounding; a better
approach to logistic regression consists of including in
the multivariable model all clinically relevant baseline
characteristics rather than only those significant in
univariable analysis
Second, from a clinical perspective, preoperative pre-
dictors of occult renal pelvis disease have limited applica-
bility in patients with ureteral tumors undergoing either
URS or SU. With regard to URS, our recent systematic review
of the literature showed that only patients with low-grade
and noninvasive UTUC should be considered for such a
procedure . It is noteworthy that intraoperative use of
a flexible ureterorenoscope [1_TD$DIFF](especially [2_TD$DIFF]combined [3_TD$DIFF]with
advanced technology[4_TD$DIFF]) allows meticulous exploration of
the urinary tract up to the renal pelvis and calyces.
Although this cannot replace the pathologist’s eye, such
macroscopic visual inspection of the entire urothelium
lining the upper urinary tract can undoubtedly outper-
form any predictive models to identify occult renal pelvis
tumors. Similarly, a preoperative endoscopic assessment
of the extent of UTUC should be systematically performed
to confirm the absence of pan-urothelial disease before
considering SU for low-risk and potentially selected
cases of high-grade and/or invasive disease according to
the results of our systematic review of the literature
. Indeed, [5_TD$DIFF]as [6_TD$DIFF]opposed to URS, we observed that most
studies comparing SU and RNU found no significant
difference in cancer-specific survival after adjusting for
disease grade and stage. However, a Cochrane risk-of-bias
assessment showed that additional confounders may
have not been controlled for, so our findings should be
interpreted with caution.
As thoughtfully emphasized by Luo et al, preoperative
selection of patients for KSS is challenging, but we believe
that only a meticulous diagnostic ureterorenoscopy can
accurately identify concomitant ureter and renal pelvis
tumors In our opinion, the controversial higher risk of
bladder recurrence related to this procedure could
largely be limited by systematic postoperative intravesical
instillation of chemotherapy . Thus, ureterorenoscopy
currently represents a key component of preoperative
staging and of postoperative follow-up for patients
undergoing any type of KSS.
Conflicts of interest: Marko Babjuk has received consultancy fees from
Bayer and Ipsen, and speaker honoraria from Ferring and GSK, and
has participated in trials for Sotio. Morgan Roupreˆt has received
consultancy fees from Lilly, GSK, Ipsen, Astellas, Takeda, and Sanofi
Pasteur, and has participated in trials for GSK. Thomas Seisen has
nothing to disclose.
References
[1]
ava ilable at
journal homepage:
DOIs of original articles: , .
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.