Radical nephroureterectomy versus endoscopic procedures for the treatment of localised upper tract urothelial carcinoma: a meta-analysis and a systematic review of current evidence from comparative studies.

The conservative management of upper tract urothelial carcinoma (UTUC) has seen important developments over the last 10 years with advances in endoscopy. Our aim was to compare the available evidence regarding the impact of endoscopic nephron sparing procedures (NSP) and radical nephroureterectomy (RNU) on survival of upper tract urothelial carcinoma (UTUC). A critical review of Pubmed/Medline, Embase and the Cochrane Central Register of Controlled Trials was performed in July 2013 according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. Overall, eight publications were selected for inclusion in this meta-analysis but all of them were retrospective or non-randomised comparative studies. The primary end points were the overall and cancer-specific survivals (OS and CSS) in the two treatment groups. We achieved to pool data on 1002 patients diagnosed with localised UTUC and treated either by endoscopic NSP (n = 322) or by RNU (n = 680). No significant difference was found in terms of OS and CSS between RNU and endoscopic NSP (HR = 1.47 and p = 0.31; HR = 0.96 and p = 0.91, respectively). However, the low level of evidence (3b) and the heterogeneity of the studies limited the quality of the results. In the absence of prospective and randomised studies, the equivalent oncologic control for endoscopic NSP and RNU is not provided by this meta-analysis. Multicentre prospective studies are urgently needed to assess the oncologic outcomes of UTUC with endoscopic management. In the next multicentre studies, the patients should be matched on the basis of the tumour stage (imaging) and grade (biopsy) at diagnosis.