Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Urology, Spedali Civili of Brescia, Brescia, Italy.
Eur Urol Oncol. 2022 Aug;5(4):451-459. doi: 10.1016/j.euo.2022.04.003. Epub 2022 May 2.
The appropriate surveillance protocol after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is still poorly addressed.
To evaluate the appropriate intensity and duration of oncologic surveillance following RNU, according to a prior history of bladder cancer (BCa).
DESIGN, SETTING, AND PARTICIPANTS: We identified 1378 high-risk UTUC patients, according to the European Association of Urology (EAU) guidelines, from a prospectively maintained database involving eight European referral centers. Surveillance protocol was based on cystoscopies and cross-sectional imaging, as per the EAU guidelines.
First, we evaluated the noncumulative risk of bladder and other-site recurrences (including distant metastasis and locoregional relapse) against the follow-up time points, as suggested by the current EAU guidelines. Second, in an effort to identify the time points when the risk of other-cause mortality (OCM) exceeded that of recurrence and follow-up might be discontinued, we relied on adjusted Weibull regression.
The median follow-up was 4 yr. A total of 427 and 951 patients with and without a prior BCa history, respectively, were considered. At 5-yr, the time point after which cystoscopies should be performed semiannually, the bladder recurrence risk was 10%; at 4 yr, the bladder recurrence risk was 13%. At 2 yr, the time point after which imaging should be obtained semiannually, the nonbladder recurrence risk was 42% in case of nonprior BCa and 47% in case of prior BCa; at 4 yr, the nonbladder recurrence risk was 23%. Among patients without a prior BCa history, individuals younger than 60 yr should continue both cystoscopies and imaging beyond 10 yr from RNU, 70-79-yr-old patients should continue only imaging beyond 10 yr, while patients older than 80 yr might discontinue oncologic surveillance because of an increased risk of OCM. Limitations include the fact that patients were treated and surveilled over a relatively long period of time.
We suggest intensifying the frequency of imaging to semiannual till the 4th year after RNU, the time point after which the risk of recurrence was almost halved. Cystoscopies could be obtained annually from the 4th year given a similar risk of recurrence at 4 and 5 yr after RNU. Oncologic surveillance could be discontinued in some cases in the absence of a prior BCa history.
In this study, we propose a revision of the current guidelines regarding surveillance protocols following radical nephroureterectomy. We also evaluated whether oncologic surveillance for high-risk upper tract urothelial carcinoma could be discontinued and, if so, in what circumstances.
根治性肾输尿管切除术（RNU）后适当的监测方案仍未得到充分解决。
根据膀胱癌（BCa）既往史，评估 RNU 后肿瘤监测的适当强度和持续时间。
设计、地点和参与者：我们根据欧洲泌尿外科学会（EAU）指南，从涉及 8 个欧洲转诊中心的前瞻性数据库中确定了 1378 例高危 UTUC 患者。监测方案根据 EAU 指南，基于膀胱镜检查和横断面成像。
首先，我们评估了膀胱癌和其他部位复发（包括远处转移和局部区域复发）的非累积风险与当前 EAU 指南建议的随访时间点的关系。其次，为了确定其他原因死亡率（OCM）风险超过复发风险且可以停止随访的时间点，我们依赖于调整后的威布尔回归。
中位随访时间为 4 年。分别考虑了 427 例和 951 例有和无 BCa 既往史的患者。在 5 年时，即应每半年进行一次膀胱镜检查的时间点，膀胱复发风险为 10%；在 4 年时，膀胱复发风险为 13%。在 2 年时，即应每半年进行一次成像检查的时间点，无 BCa 既往史的患者中非膀胱癌复发风险为 42%，有 BCa 既往史的患者中非膀胱癌复发风险为 47%；在 4 年时，非膀胱癌复发风险为 23%。在没有 BCa 既往史的患者中，60 岁以下的患者应在 RNU 后 10 年以上继续进行膀胱镜检查和影像学检查，70-79 岁的患者应在 10 年以上仅进行影像学检查，而 80 岁以上的患者可能由于 OCM 风险增加而停止肿瘤监测。局限性包括患者接受治疗和监测的时间相对较长。
我们建议将影像学检查的频率增加到每半年一次，直到 RNU 后 4 年，此时复发风险几乎减半。鉴于 RNU 后 4 年和 5 年的复发风险相似，此后可每年进行一次膀胱镜检查。在没有 BCa 既往史的情况下，某些情况下可以停止肿瘤监测。
在这项研究中，我们提出了对根治性肾输尿管切除术后监测方案的现行指南进行修订。我们还评估了是否可以停止高危上尿路上皮癌的肿瘤监测，如果可以，在什么情况下可以停止。
