BACKGROUND: The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories. OBJECTIVE: To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points. RESULTS AND LIMITATIONS: A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU). CONCLUSIONS: Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design. PATIENT SUMMARY: We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.

Department of Genitourinary Oncology Moffitt Cancer Center Tampa FL USA

Department of Genitourinary Oncology Moffitt Cancer Center Tampa FL USA; Department of Surgery Division of Urology Hôpital du Sacré Coeur de Montréal University of Montreal Montreal Canada

Department of Surgery Division of Urology McGill University Health Center Montreal Canada

Department of Surgery Division of Urology McGill University Health Center Montreal Canada; Urology Department Claude Huriez Hospital CHU Lille Lille France

Department of Urology Bichat Claude Bernard Hospital AP HP Paris Descartes University Paris France

Department of Urology Careggi Hospital University of Florence Florence Italy

Department of Urology Jagiellonian University Medical College Krakow Poland

Department of Urology Jikei University School of Medicine Tokyo Japan

Department of Urology Johns Hopkins University School of Medicine Baltimore MD USA

Department of Urology Kaohsiung Medical University Hospital Kaohsiung Taiwan; Department of Urology School of Medicine Kaohsiung Medical University Kaohsiung Taiwan

Department of Urology MD Anderson Cancer Center Houston TX USA

Department of Urology MD Anderson Cancer Center Houston TX USA; Department of Urology and Kidney Transplant The University of Toledo Medical Center and Eleanor N Dana Cancer Center Toledo OH USA

Department of Urology Medical University of Vienna Vienna Austria

Department of Urology Medical University of Vienna Vienna Austria; Department of Urology Kantonsspital Winterthur Winterthur Switzerland

Department of Urology Medical University of Vienna Vienna Austria; Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan

Department of Urology Medical University of Vienna Vienna Austria; Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan; Department of Urology University of Texas Southwestern Medical Center Dallas TX USA; Department of Urology Weill Cornell Medical College New York NY USA; Karl Landsteiner Institute of Urology and Andrology Vienna Austria; Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic; Institute for Urology and Reproductive Health 1 M Sechenov 1st Moscow State Medical University Moscow Russia

Department of Urology Medical University of Vienna Vienna Austria; Division of Urology Department of Surgical Sciences University of Torino School of Medicine Turin Italy

Department of Urology Provincial Hospital of Bozen Bozen Italy; Medical School Sigmund Freud University Vienna Austria

Department of Urology Seoul National University Hospital Seoul Korea

Department of Urology The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital Amsterdam The Netherlands

Department of Urology University Hospitals Leuven Leuven Belgium

Department of Urology University of Rennes Rennes France

Department of Urology University of Texas Southwestern Medical Center Dallas TX USA

Department of Urology University of Texas Southwestern Medical Center Dallas TX USA; Department of Urology University Hospital Muenster Muenster Germany

Department of Urology Uro Oncology University Hospital Cologne Cologne Germany

Division of Oncology Unit of Urology Urological Research Institute IRCCS Ospedale San Raffaele Vita Salute San Raffaele University Milan Italy

Division of Oncology Unit of Urology Urological Research Institute IRCCS Ospedale San Raffaele Vita Salute San Raffaele University Milan Italy; Department of Urology Luzerner Kantonsspital Lucerne Switzerland

Division of Urology Virginia Commonwealth University Richmond VA USA

Instituto Valenciano de Oncologia Foundation Valencia Spain

Urology GRC 5 Predictive ONCO URO Pitié Salpêtrière Hospital AP HP Sorbonne University Paris France

References provided by Crossref.org

Need for and extent of lymph node dissection for upper tract urothelial carcinoma: an updated review in 2023