Oncologic and surgical outcomes of endoscopic therapy compared to surgical treatment of upper tract urothelial carcinoma stratified by tumor grade

Abstract

Introduction: Oncologic outcomes of endoscopic treatment (ET) vs. extirpative surgery (ES=radical nephroureterectomy/segmental ureterectomy [RNU, SU]) for upper tract urothelial carcinoma (UTUC) are not well-defined. We queried the National Cancer Database to compare the overall survival (OS) and surgical outcomes of ET to ES for localized UTUC stratified by grade. Methods: We conducted a retrospective cohort study including patients 18−90 years old, diagnosed with localized UTUC from 2004−2021. The primary outcome was OS. Secondary outcomes included the surgical outcomes of postoperative mortality, length of hospital stay, and 30-day readmission rate. We conducted 1:1 propensity-score matching (PSM). Survival analysis by accelerated failure time model with Weibull distribution with clustering (reporting time ratio [TR] and 95% confidence interval [CI]) was conducted. Mann-Whitney test or Fisher’s exact test were used to compare other outcomes. Results: ET was used to treat 3.6% of UTUC cases in 2004 to 9.8% in 2020. After all inclusion and exclusion, there were 32 205 patients: 1747 (5.42%) in the ET arm and 30458 (94.58%) in the ES arm. After PSM, 1541 patients were included in each cohort. For high-grade UTUC, ET vs. ES was associated with reduced OS (TR: 0.51, 95% CI 0.39−0.65). For low-grade UTUC, ET vs. ES was not associated with diminished OS (TR 0.88, 95% CI 0.72−1.07). Conclusions: In appropriately selected patients with low-grade UTUC, ET appears to confer comparable survival outcomes to extirpative approaches; however, in those with high-grade UTUC, we found lower OS among those managed with ET. This may be from poorer cancer control or may reflect residual confounding among those patients selected for ET (e.g., greater comorbidity or conditions precluding ES).