Survival Outcomes Across Surgical Approaches in Octogenarians with UTUC

Upper tract urothelial carcinoma (UTUC) represents 5% of urothelial cancers, yet it can be highly aggressive and associated with poor prognosis. The standard of care is radical nephroureterectomy (RNU) with bladder cuff resection and perioperative chemotherapy. However, surgery carries risks and complications, particularly in patients with comorbidities. Advances in recent years have allowed some patients to receive nephron-sparing surgery, but this requires careful consideration of potential risk versus benefit of a conservative approach. Wang et al. aimed to investigate the impact of different surgical approaches on outcomes among octogenarians with UTUC.

The investigators collected data for 744 patients from the Surveillance, Epidemiology, and End Results (SEER) database. This included 205 patients who received no surgery (NS), 181 patients who received local intervention such as segmented ureterectomy or endoscopic local tumor resection (LI), and 388 patients who received radical surgery (RS). There were significant differences in demographic and clinical factors across the three groups, whereby more patients in the NS group were older, of African American ethnicity, and single, in addition to having T1 stage tumors and receiving radiation therapy (all p < 0.001). More patients in the LI group had tumors in the ureter and received chemotherapy compared to the other two groups (all p < 0.001). Patients in the RS group had the highest proportion of high-grade tumors (p < 0.001). A multivariate logistic analysis showed that older patients (p < 0.05) and African American patients (p = 0.018) were less likely to be treated surgically. The median follow-up was 76.0 months, during which 69.9% of deaths occurred overall, representing 86.3% of patients in the NS group, 63.5% of patients in the LI group, and 64.2% of patients in the RS group (p < 0.001). Less than half (45.7%) of these deaths were caused by non-UTUC reasons, corresponding to 30.5%, 47.8%, and 55.4% of patients in the NS, LI, and RS groups, respectively (p < 0.001). The median overall survival (OS) was longer in the LI (35 months) and RS (47 months) groups compared to the NS group (13 months; p < 0.001). This pattern was consistent across 5-year OS and 5-year disease-specific survival (DSS) measures (all p < 0.001). In contrast, there were no significant differences in survival outcomes between the LI and RS groups (p > 0.05).

The findings from this study highlight the potential value of conservative, nephron-sparing surgery in older patients with UTUC. Since survival outcomes were not significantly different in patients who received radical versus conservative surgery, the latter approach could reduce the risk of postoperative complications and renal insufficiency in select patients. Adherence to follow-up is an important factor to consider when selecting treatment. Data regarding comorbidities and postoperative complications were not available and could not be investigated in this study. Prospective studies should be carried out in this patient population to validate these strategies.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

Reference:

Wang S, Phelan M, Siddiqui MM. Impact of surgical management of upper tract urothelial cancer in octogenarians: A population-based study. Curr Urol. 2024;18(3):225-231. doi:10.1097/CU9.0000000000000164

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