Re: Long-term Outcomes of Immediate Versus Delayed Nephroureterectomy for Upper Tract Urothelial Carcinoma

Dear Editor:

I n this study, Gadzinski and associates demonstrate no difference in 5-year cancer-specific survival and metastasis-free survival among patients undergoing immediate nephroureterectomy (NUx) and delayed (on average, after 10 months) NUx for small and low-grade upper urinary tract urothelial tumor after endoscopic management. This is in contradiction to a multicentric study of 187 patients who demonstrated that a delay >45 days between diagnosis and resection of the tumor constitutes a risk for disease progression. ¹

The diagnosis of upper tract urothelial carcinoma is fortuitous or related to the exploration of symptoms, ² which tend to be generally restricted. ³ Radiologic investigations often fail to detect small tumors, adding to the diagnostic dilemma. ⁴ Thus, patients usually present with advanced disease that is not amenable to endoscopic management. Moreover, endoscopic treatment necessitates advanced instrumentations (such as flexible endoscopes, lasers etc.), dedicated team, and high surgical expertise. At present, such treatment can be offered only at select centers of the world, thus limiting the wide use of this technique all over the globe.

On average, eight patients underwent 42 operations (37 ureteroscopies, 5 percutaneous procedures; 5.2 operations per patient) every 3.7±1.0 months while on active surveillance. In an elderly group of patients, repeated procedures under anesthesia may be difficult, while repeated ureteroscopies and laser ablation can lead to iatrogenic ureteral strictures as well, further increasing the morbidity.