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The Role of Prior Bladder Cancer on Recurrence in Patients Treated with Radical Nephroureterectomy

Published:December 11, 2021DOI:https://doi.org/10.1016/j.clgc.2021.12.006

      Clinical Practice Points

      • To date, the prognostic role of prior bladder cancer (BCa) among patients with upper tract urothelial carcinoma (UTUC) is still poorly addressed.
      • We aimed to investigate the role of prior BCa on any recurrence (aR), distant metastasis (DM), and bladder recurrence following RNU among low-grade (LG) and high-grade (HG) UTUC patients.
      • We retrospectively analyzed a multicenter cohort of 1,580 patients treated with radical nephroureterectomy (RNU) for UTUC. Median follow-up was 4 years.
      • The Kaplan-Meier curves were applied to assess aR, DM, and bladder recurrence, computed from the time of RNU. Multivariable Cox models were generated to predict the risk of aR, DM, and bladder recurrence. All analyses were stratified by tumor grade (LG and HG), site of recurrence (aR, DM, and bladder recurrence), and prior history of BCa (no prior BCa, non-muscle-invasive [NMIBC], and muscle-invasive bladder cancer [MIBC]).
      • Both LG and HG UTUC patients with prior BCa had a significantly increased risk of aR and bladder recurrence on multivariable Cox models, compared to individuals with no prior BCa.
      • The main strength of our paper is represented by the fact that this is the first study in which analyses were stratified according to both UTUC grade and muscle-invasiveness of prior BCa history. Additionally, our cohort represent the largest cohort available in literature that evaluates the role of prior BCa on aR after RNU for UTUC.
      • The present study is limited by its retrospective design and the lack of some information on prior BCa, such as multifocality or previous intravesical therapy.

      Abstract

      Introduction

      The prognostic role of prior history of bladder cancer (BCa) among patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is poorly addressed. We aimed to investigate the role of prior BCa on any recurrence, distant metastases, and bladder recurrence following RNU among low-grade (LG) and high-grade (HG) UTUC patients.

      Patients and Methods

      We retrospectively analyzed 1,580 UTUC patients treated with RNU at 8 tertiary referral centers between 1992 and 2016. Any recurrence was defined as recurrence in the urinary tract, in the resection bed, or distant metastases (defined as disease outside the urinary tract and regional lymph nodes). Time to recurrence was computed from RNU. Multivariable Cox models were generated to predict risk of any recurrence, distant metastases, and bladder recurrence according to prior BCa history, coded as no prior BCa, non-muscle-invasive (NMIBC), and muscle-invasive BCa (MIBC).

      Results

      Median follow-up for survivors was 4 years. Overall, 71%, 25%, and 4% of patients had no prior BCa, NMIBC and MIBC. 5-year any recurrence-free survival was 61%, 41%, and 19% in LG (P < .001) and 42%, 34%, and 30% in HG patients (P = .1) with no prior BCa, NMIBC, and MIBC. On multivariable models, LG patients with NMIBC and MIBC showed a significantly higher risk of any recurrence compared to no prior BCa (both p≤0.005); previous NMIBC was associated with any recurrence among HG patients (P = 0.04). 5-year distant metastases-free survival was 92%, 90%, and 87% in LG (P > .05) and 68%, 75%, and 45% in HG patients (P = .01) with no prior BCa, NMIBC, and MIBC. Previous NMIBC increased the risk of bladder recurrence among LG (P < .001) and HG (P = .003) patients.

      Conclusions

      UTUC patients with prior history of BCa exhibit a higher risk of any recurrence after RNU. Our study provides important information which could address patient's counseling and decision-making process.

      Keywords

      Abbreviations:

      UTUC (upper tract urothelial carcinoma), RNU (radical nephroureterectomy), BCa (bladder cancer), AC (adjuvant chemotherapy), NMIBC (non-muscle-invasive bladder cancer), MIBC (muscle-invasive bladder cancer), HG (high grade), LG (low grade), CI (confidence interval), HR (hazard ratio)
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