沈志宇¹、蔡育賢¹、詹皓程¹、歐建慧¹、楊文宏¹、蔡宗欣²

¹成功大學醫學院附設醫院泌尿部；²中國醫藥大學安南醫院泌尿部

Chih-Yu Shen¹, Yuh-Shyan Tsai¹, Jan Hau-Chern¹, Chien Hui Ou¹, Wen Horng Yang¹, Tzong-Shin Tsai²

¹Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

²Department of Urology, An-Nan Hospital; Department of Urology, School of Medicine, China Medical University, Taichung, Taiwan

 

Purpose: This study compares long-term outcomes between radical nephroureterectomy(RNU) and kidney-sparing surgery (KSS) to upper tract urothelial carcinoma, using inverse probability of treatment weighting (IPTW) based on propensity scores to control for selection bias.

Materials and Methods: Patients undergoing radical nephroureterectomy and kidney-sparing surgery for Ta/T1 upper tract urothelial carcinoma from 2004 to 2018 were analysed. Inverse probability of treatment weighting (IPTW) based on propensity scores were generated in an effort to adjust for potential bias due to non-randomization and used to assess the marginal treatment effect of the kidney sparing surgery via a weighted Cox proportional hazards model. Oncologic outcomes including overall survival, progression free survival, and renal function assessed 12 months after treatment were evaluated.

Results: A total of 184 patients with cTa/T1 UTUC were initially included and those with end stage renal disease (ESRD) or without previous ureteroscopic biopsy were excluded from the study. Finally a total of 65 patients were enrolled for analysis, of which, 23 received KSS and 42 received RNU. After IPTW, the population was well balanced. With a median follow up of 43.60 months, weighted Kaplan-Meier survival analysis showed no difference in 5-year overall survival (OS) (94.48 % vs 94.57%, p=0.55) and recurrence-free survival (RFS) (58.60 % vs 61.81%, p=0.89) between KSS cohort and RNU cohort. The estimated glomerular filtration rate (eGFR) decreased 20.2% and 0.0% one year after the operation in the RNU cohort and KSS cohort respectively (p<0.001). Linear regression demonstrated that operation type (p=0.011) and gender (p=0.002) was significantly associated with eGFR changes 12 months after operation in multivariable model. The renal salvage rate was 60.86% and 5 year RNU-free survival was 64.6% in our study.

Conclusion: In our experience, after accounting for bias in treatment assignment, endoscopic management of urothelial carcinoma provides equivalent oncologic outcomes in regards of OS and PFS when compared with RNU. The benefit of renal function preservation was also demonstrated in our study. It is therefore, a reasonable approach to treat selected patients with a meticulous and stringent postoperative follow up schedule.