Urology Department, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
Urol Oncol. 2021 Oct;39(10):733.e11-733.e16. doi: 10.1016/j.urolonc.2021.06.007. Epub 2021 Jun 17.
The pandemic of COVID-19 has disrupted the clinical pathway for patients with suspected upper tract urothelial carcinoma (UTUC). This aims to investigate the optimal management of UTUC during the pandemic by determining 1) Whether a three-month delay of RNU leads to worsened overall survival, 2) Whether radical nephroureterectomy (RNU) can be performed without prior diagnostic ureteroscopy (URS).
Consecutive patients with RNU performed for suspected UTUC in four hospitals in Hong Kong and Taiwan were included. Patients with histologically proven UTUC and with RNU performed within one year were dichotomized into early (≤3 months) and delayed (>3 months) RNU groups. Diagnostic performances of predictive models based on pre-URS factors (gross haematuria, suspicious or malignant urine cytology, and filling defect or contrast-enhancing mass on computed tomography), with or without URS, were analysed using receiver operating characteristics and area under curve (AUC). Overall survival was analysed using Kaplan-Meier method and multivariate Cox regression analysis.
Between 2000 and 2019, 665 patients underwent RNU, and 491 of them had prior diagnostic URS. The early RNU group had a better overall survival (P = 0.015). Early RNU was associated with a better overall survival upon multivariate analysis (HR 1.55, 95% CI 1.03-2.33, P = 0.035). Large tumour size, multi-focal tumour, T2 or above disease, and positive nodal status were associated with a poorer overall survival. A combination of any 2 out of the 3 pre-URS factors achieved a positive predictive value of 99.5 to 100%. Presence of all 3 pre-URS factors achieved an AUC of 0.851 with URS, and AUC of 0.809 without URS.
A delay of RNU for over 3 months was associated with poorer overall survival and has to be avoided despite the current COVID-19. We can also consider direct RNU based on clinical factors alone. This also avoids URS hospitalization and expedites the clinical pathway of UTUC.
COVID-19 大流行打乱了疑似上尿路尿路上皮癌（UTUC）患者的临床路径。本研究旨在通过确定 1）RNU 延迟 3 个月是否会导致总生存恶化，2）是否可以在没有术前诊断性输尿管镜检查（URS）的情况下进行根治性肾输尿管切除术（RNU），来探讨大流行期间 UTUC 的最佳治疗方法。
纳入了在香港和台湾的 4 家医院接受 RNU 治疗的连续疑似 UTUC 患者。将经组织学证实患有 UTUC 且在一年内接受 RNU 治疗的患者分为早期（≤3 个月）和晚期（>3 个月）RNU 组。分析了基于术前 URS 因素（肉眼血尿、可疑或恶性尿液细胞学、计算机断层扫描充盈缺损或增强肿块）的预测模型的诊断性能，包括是否进行 URS。使用受试者工作特征曲线和曲线下面积（AUC）进行分析。使用 Kaplan-Meier 方法和多变量 Cox 回归分析进行总生存分析。
在 2000 年至 2019 年期间，有 665 例患者接受了 RNU，其中 491 例患者进行了术前诊断性 URS。早期 RNU 组的总生存更好（P=0.015）。多变量分析显示，早期 RNU 与更好的总生存相关（HR 1.55，95%CI 1.03-2.33，P=0.035）。肿瘤较大、多灶性、T2 或以上疾病和淋巴结阳性与总生存较差相关。任何 2 项术前 URS 因素的组合可达到 99.5%至 100%的阳性预测值。3 项术前 URS 因素均存在时，AUC 为 0.851（有 URS）和 0.809（无 URS）。
RNU 延迟 3 个月以上与总生存恶化相关，即使在当前 COVID-19 大流行期间也应避免这种情况。我们也可以仅根据临床因素考虑直接进行 RNU。这也避免了 URS 住院治疗，并加快了 UTUC 的临床路径。
