To Analyze The Effect Of Preoperative Ureteroscopy On Intravesical Recurrence And Long-term Survival After Radical Nephroureterectomy For Upper Tract Urothelial Carcinoma

Objective To investigate the effect of preoperative ureteroscopy(URS)on intravesical recurrence(IVR)and long-term survival in patients with upper tract urothelial carcinoma(UTUC)after radical nephroureterectomy.Methods The clinical data of 426 UTUC patients admitted to the second Hospital of Lanzhou university from May 2012 to June 2022 were retrospectively analyzed.According to the inclusion and exclusion criteria,375 UTUC patients who underwent RNU were finally included.According to whether URS was performed before operation,the patients were divided into URS group and non-URS group.There were 207 males and 168 females,with an average age of 65.4±9.1(38-91)years,including 173 patients≤65 years old and 202 patients＞65 years old.There were108 cases of hypertension and 38 cases of diabetes.The main symptom was gross hematuria in 266 cases.The tumor diameter was≤3cm in 197 cases and＞3cm in 178 cases.There were 188 cases on the left side and 187 cases on the right side.The tumors were located in the renal pelvis in 196 cases,in the ureter in 155 cases,and in both renal pelvis and ureter in 24 cases.There were 209 cases of preoperative hydronephrosis.Thirty-three patients had a history of bladder cancer(BC)or BC at initial diagnosis.The clinical and pathological data of URS group and non-URS group were compared.The cumulative IVR rate,overall survival(OS),cancer-specific survival(CSS)and progression-free survival(PFS)after RNU were compared by Kaplan-Meier survival analysis.The survival curve was drawn.Cox proportional hazards model was used to analyze the effect of URS on IVR,OS,CSS and PFS of UTUC patients after surgery.Results A total of 375 UTUC patients were enrolled,including 83 in the URS group and 292 in the non-URS group.Of the 83 patients in the URS group,61 underwent biopsy and 22 did not.There were no significant differences in age,gender,history of hypertension,history of diabetes,tumor side,history of BC or combined BC,surgical method,tumor grade and positive surgical margin(all P≥0.05)between the two groups.There were significant differences in hematuria,tumor diameter,tumor location,tumor stage and preoperative hydronephrosis(all P < 0.05).Up to December 2022,the median follow-up time of all patients was 41(3-127)months,and the median recurrence time was 11(3-56)months.IVR occurred in 25 patients(30.1%)in the URS group and 40 patients(13.7%)in the non-URS group,and a total of 65 patients(17.3%)had IVR.Local recurrence and distant metastasis occurred in57 patients,including 14 in the URS group and 43 in the non-URS group,including22 cases of local recurrence and 35 cases of distant metastasis.90 patients died,including 24 in the URS group and 66 in the non-URS group.There were 72 cases of tumor-specific death,including 21 cases in the URS group and 51 cases in the non-URS group.Kaplan-Meier survival analysis showed that the 1,3 and 5-year cumulative IVR rates of all patients were 11.6%,18.8% and 23.2%,respectively.Regardless of whether patients with bladder cancer(BC)or BC history were excluded,the cumulative IVR rate of URS group was higher than that of non-URS group(all P<0.05).However,the PFS of the URS group was significantly lower than that of the non-URS group(P=0.006).The cumulative IVR of patients with and without biopsy in URS group at 1,3,and 5 years after surgery were 18.2%,26.8%,32.8% and 15.1%,44.6%,53.9%,respectively,and the difference was not statistically significant(P=0.229).The 1,3,and 5-year OS of URS group and non-URS group were 91.1%,72.5%,66.7% and 89.4%,78.0%,73.8%,respectively,CSS were 91.1%,74.8%,70.4% and 90.7%,83.0%,79.1%,respectively(P=0.503 and P=0.269).Cox multivariate regression analysis showed that URS(P=0.031)was an independent risk factor for IVR,URS and renal pelvic and ureteral tumors were independent risk factors for PFS(P=0.007 and P=0.019),URS had no negative effect on OS and CSS(P=0.125 and P=0.074).However,advanced age,tumor diameter>3cm,T3-T4 stage tumor and high tumor grade were independent risk factors for shortened OS and CSS(all P<0.05).Conclusion Preoperative URS can increase the incidence of IVR in UTUC patients,URS can increase the postoperative progression of UTUC patients.It is not recommended to use URS routinely before surgery,unless the preoperative imaging of the patient can not be definitively diagnosed or clinicians need more information to guide clinical decision-making.At the same time,preventive methods should be considered to reduce the incidence of IVR,thereby avoiding repeated surgical intervention or late BC in high-risk patients.Moreover,our results showed that URS had no effect on OS and CSS,while advanced age,tumor diameter>3cm,T3-T4 stage tumor and high tumor grade had effect on OS and CSS.