Background: Measuring quality of care indicators is important for clinicians and decision making in health care to improve patient outcomes. Objective: The primary objective was to identify quality of care indicators for patients with upper tract urothelial carcinoma (UTUC) and to validate these in an international cohort treated with radical nephroureterectomy (RNU). The secondary objective was to assess the factors associated with failure to validate the pentafecta. Design: We performed a retrospective multicenter study of patients treated with RNU for EAU high-risk (HR) UTUC. Outcome measurements and statistical analysis: Five quality indicators were consensually approved, including a negative surgical margin, a complete bladder-cuff resection, the absence of hematological complications, the absence of major complications, and the absence of a 12-month postoperative recurrence. After multiple imputations and propensity-score matching, log-rank tests and a Cox regression were used to assess the survival outcomes. Logistic regression analyses assessed predictors for pentafecta failure. Results: Among the 1718 included patients, 844 (49%) achieved the pentafecta. The median follow-up was 31 months. Patients who achieved the pentafecta had superior 5-year overall- (OS) and cancer-specific survival (CSS) compared to those who did not (68.7 vs. 50.1% and 79.8 vs. 62.7%, respectively, all p < 0.001). On multivariable analyses, achieving the pentafecta was associated with improved recurrence-free survival (RFS), CSS, and OS. No preoperative clinical factors predicted a failure to validate the pentafecta. Conclusions: Establishing quality indicators for UTUC may help define prognosis and improve patient care. We propose a pentafecta quality criteria in RNU patients. Approximately half of the patients evaluated herein reached this endpoint, which in turn was independently associated with survival outcomes. Extended validation is needed.

Department of Urology 2nd Faculty of Medicine Charles University 11638 Prague Czech Republic

Department of Urology Azienda Ospedaliera Universitaria Integrata of Verona University of Verona 37129 Verona Italy

Department of Urology Comprehensive Cancer Center Medical University of Vienna 1090 Vienna Austria

Department of Urology Erasmus MC Cancer Institute University Medical Center 3015 GD Rotterdam The Netherlands

Department of Urology Faculty of Medicine Kindai University Osaka 577 8502 Japan

Department of Urology Icahn School of Medicine at Mount Sinai New York NY 10029 USA

Department of Urology La Croix du Sud Hospital 31130 Toulouse France

Department of Urology Lions Gate Hospital North Vancouver BC V7L 2L7 Canada

Department of Urology Luzerner Kantonsspital 6004 Lucerne Switzerland

Department of Urology Mayo Clinic Rochester MN 55905 USA

Department of Urology Medical University of Silesia 41 808 Zabrze Poland

Department of Urology Paracelsus Medical University Salzburg University Hospital Salzburg 5020 Salzburg Austria

Department of Urology St Marianna University School of Medicine Kawasaki 216 8511 Japan

Department of Urology University Hospital Zurich 8091 Zurich Switzerland

Department of Urology University Medical Center Hamburg Eppendorf 20251 Hamburg Germany

Department of Urology University of Rennes 35000 Rennes France

Department of Urology University of Texas Southwestern Dallas TX 75390 USA

Department of Urology Uro Oncology Robot Assisted and Specialized Urologic Surgery University Hospital Cologne 50937 Cologne Germany

Department of Urology USC Norris Comprehensive Cancer Center Los Angeles CA 90033 USA

Department of Urology Weill Cornell Medical College New York NY 10021 USA

Division of Urology Department of Surgery College of Medicine The Pennsylvania State University Hershey PA 16801 USA

Division of Urology Department of Surgical Sciences San Giovanni Battista Hospital University of Studies of Torino 10124 Turin Italy

Hourani Center for Applied Scientific Research Al Ahliyya Amman University Amman 19328 Jordan

Institute for Urology and Reproductive Health Sechenov University 119048 Moscow Russia

Karl Landsteiner Institute of Urology and Andrology 1010 Vienna Austria

Unit of Oncologic Minimally Invasive Urology and Andrology Department of Experimental and Clinical Medicine Careggi Hospital University of Florence 50134 Florence Italy

Urology Department Fundació Puigvert Autonomous University of Barcelona 08193 Barcelona Spain

Urology Department GRC n°5 Predictive Onco Uro AP HP Pitié Salpêtrière Hospital Sorbonne University 75006 Paris France

USC Institute of Urology Keck Medicine of USC University of Southern California Los Angeles CA 90007 USA

Vattikuti Urology Institute Henry Ford Hospital Detroit MI 48202 USA

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