High rates of advanced disease, complications, and decline of renal function after radical nephroureterectomy

Jay D. Raman, Yu Kuan Lin, Matthew Kaag, Timothy Atkinson, Paul Crispen, Mark Wille, Norm Smith, Mark Hockenberry, Thomas Guzzo, Benoit Peyronnet, Karim Bensalah, Jay Simhan, Alexander Kutikov, Eugene Cha, Michael Herman, Douglas Scherr, Shahrokh F. Shariat, Stephen A. Boorjian

Research output: Contribution to journalArticle

35 Scopus citations

Abstract

Objectives: Recurrences remain common following radical nephroureterectomy (RNU) for locally advanced upper-tract urothelial carcinoma (UTUC). We review a cohort of RNU patients to identify the incidence of locally advanced disease, decline in renal function, complications, and utilization of adjuvant chemotherapy (AC). Methods: Institutional databases from 7 academic medical centers identified 414 RNU patients treated between 2003 and 2012 who had not received neoadjuvant chemotherapy. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease equation. Complications were classified according to the modified Clavien system. Cox proportional hazard modeling and Kaplan-Meier analysis determined factors associated with cancer-specific survival. Results: Of 414 patients, 177 (43%) had locally advanced disease, including 118 pT3N0/Nx, 13 pT4N0/Nx, and 46 pTanyN+. Estimated 3- and 5-year cancer-specific survival was 47% and 34%, respectively. Only 31% of patients with locally advanced UTUC received AC. Mean estimated glomerular filtration rate declined from 59 to 51ml/min/1.73m2 following RNU, including a new-onset decline below 60 and 45ml/min/1.73m2 in 25% and 15% of patients, respectively (P<0.001 for both). Complications occurred in 46 of 177 (26%) patients, of which one-quarter were grade III or IV. Increasing age (Hazard Ratio (HR) 1.4, P = 0.03), positive surgical margins (HR 2.1, P = 0.01), and positive lymph nodes (HR 4.3, P<0.001) were associated with an increased risk of death from UTUC, whereas receipt of AC (HR 0.85, P = 0.05) was associated with a decrease in UTUC mortality. Conclusions: Under one-third of RNU patients with locally advanced UTUC cancers received AC. Perioperative complications and decline in renal function may have contributed to this low rate. Such data further underscore the need for continued discussion regarding the use of chemotherapy in a neoadjuvant setting for appropriately selected patients with UTUC.

Original languageEnglish (US)
Pages (from-to)47.e9-47.e14
JournalUrologic Oncology: Seminars and Original Investigations
Volume32
Issue number1
DOIs
StatePublished - Jan 2014

Keywords

  • Clavien complications
  • Locally advanced disease
  • Perioperative chemotherapy
  • Renal-function changes
  • Urothelial carcinoma

ASJC Scopus subject areas

  • Oncology
  • Urology

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    Raman, J. D., Lin, Y. K., Kaag, M., Atkinson, T., Crispen, P., Wille, M., Smith, N., Hockenberry, M., Guzzo, T., Peyronnet, B., Bensalah, K., Simhan, J., Kutikov, A., Cha, E., Herman, M., Scherr, D., Shariat, S. F., & Boorjian, S. A. (2014). High rates of advanced disease, complications, and decline of renal function after radical nephroureterectomy. Urologic Oncology: Seminars and Original Investigations, 32(1), 47.e9-47.e14. https://doi.org/10.1016/j.urolonc.2013.06.015