Open radical nephroureterectomy (RNU) has been established as the gold standard of treatment for upper urothelial carcinoma; however, based on early postoperative convalescence and a better cosmetic outcome, laparoscopic RNU has now emerged as an alternative treatment method to open RNU, and a robot-assisted procedure is now spreading mainly in Western countries, with acceptable short-term outcomes [Citation1, Citation2]. As a kidney-sparing surgery, tumor ablation has been performed for selected patients (such as for single, low grade, and noninvasive disease or imperative indication such as in patients with pre-existing chronic kidney disease), and segmental ureterectomy (SU) is also a treatment option for patients with low risk tumors [Citation3].
In the present study, the authors evaluated oncological outcomes after SU or RNU for high-risk ureteral carcinoma [Citation4]. In 63 patients (24 in SU group, 39 in RNU group) who had at least one high-risk factor, no significant difference was found in recurrence-free survival (66.7% and 69.2%, p = 0.798), overall survival (79.2% and 84.6%, p = 0.453) and cancer-specific survival (83.3% and 89.7%, p = 0.405) between SU and RNU groups, respectively. In addition, as a matter of course, a better postoperative renal function was observed in the SU cohort. Their survival outcomes were promising, and, as they mentioned, SU would have the advantage of completely resecting the lesion with a negative margin compared with endoscopic tumor ablation. In an international multi-institutional retrospective study, although there was a large difference in the sample size between SU (n = 81) and RNU (n = 754), Bagrodia et al. also observed similar oncologic outcomes between SU and RNU [Citation5].
However, these observations should be carefully interpreted. Neither study clarified surgical indications for SU or RNU. It is not clear how we should follow those patients, such as the ideal interval between CT scans, or the necessity of regular examinations using ureteroscopy or that of adjuvant chemotherapy. Considering the difficulty of patient recruitment, a randomized study would be very difficult to assess the oncological equivalence between the two methods, and so RNU should remain the gold standard and SU should be performed for carefully selected patients.
DISCLOSURE STATEMENT
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
- Aboumohamed AA, Krane LS, Hemal AK. Oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma. J Urol. 2015;194(6):1561–1566. DecPubMed PMID: 26192256.
- Ambani SN, Weizer AZ, Wolf JS, Jr., He C, Miller DC, Montgomery JS. Matched comparison of robotic vs laparoscopic nephroureterectomy: an initial experience. Urology 2014;83(2):345–349. FebPubMed PMID: 24315310.
- Roupret M, Babjuk M, Comperat E, et al. European association of urology guidelines on upper urinary tract urothelial carcinoma: 2017 update. Eur Urol. 2018; 73(1):111–122.
- Huang Z, Zhang X, Zhang X, Li Q, Liu S, Yu L, Xu T. Segmental Ureterectomy is Acceptable for High-risk Ureteral Carcinoma Comparing to Radical Nephroureterectomy. Journal of Investigative Surgery (in press).
- Bagrodia A, Kuehhas FE, Gayed BA, et al. Comparative analysis of oncologic outcomes of partial ureterectomy vs radical nephroureterectomy in upper tract urothelial carcinoma. Urology 2013;81(5):972–977. MayPubMed PMID: 23523292.