Upper tract urothelial carcinoma: impact of time to surgery

Patients diagnosed with upper tract urothelial carcinoma (UTUC) sometimes experience a delay from diagnosis to extirpative surgery (nephroureterectomy or ureterectomy) as a result of attempted endoscopic management and/or neoadjuvant chemotherapy. The purpose of this analysis is to examine the impact of such delay on survival outcomes.

An IRB-approved retrospective review identified consecutive patients undergoing extirpative surgery for UTUC treated at a single institution between 1990 and 2007. 240 patients with non-metastatic disease represented both primarily-presenting and referred patients. Patients in the "early" surgery group underwent extirpative surgery <3 months after diagnosis and patients in the "delayed" surgery group underwent surgery ≥ 3 months after diagnosis. Timing to surgery was at the discretion of individual patient-surgeon decision-making. Analyses and measurements were univariate and multivariate models correlating death from disease with clinico-pathologic parameters, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in the "early" and "delayed" surgery groups.

186 patients underwent early surgery and 54 patients underwent delayed surgery. Median follow-up for all patients was 29 months. The 5-year CSS were 72% and 71% for the early versus late groups, respectively (P = 0.39) and corresponding 5-year OS rates were 60% and 69%, respectively (P = 0.69). Delay in surgery was not associated with a worse outcome, even following adjustment for potential confounders. The most common factor contributing to delayed surgery in our cohort was administration of neoadjuvant chemotherapy (50%), which did not impact survival. Limitations included a median follow-up of 19 months in the neoadjuvant group; and the requirement to analytically group pathologic high-stage and low-stage disease, which reflects challenges inherent to current clinical staging.

Our results show no difference in survival between patients undergoing early versus delayed extirpative surgery for UTUC, suggesting the feasibility of delayed surgery in appropriately selected patients. Only prospective validation of delayed surgery can guarantee its safety.