Re; Sarmah PB, Ehsanullah SA, Sarmah BD. Long-term follow-up and outcomes of percutaneous nephron-sparing surgery for upper tract urothelial carcinoma. Indian J Urol 2020;36:276-81.

Dear Editor,

We read with great interest the study[1] on the outcomes of percutaneous nephron-sparing surgery (PCNSS) in upper tract urothelial carcinoma (UTUC). Radical nephroureterectomy (RNU) is considered the standard of care in high-risk cases.[2] Nephron-sparing surgery (NSS) may be a necessary alternative in patients with a solitary kidney, multiple bilateral UTUC, significant comorbidities, or renal impairment, which will incur unacceptable risk with RNU.[3] This study is a welcome addition to the very sparse data on the outcomes of this approach in UTUC.

European Association of Urology (EAU) guidelines advise NSS in all low-risk cases. Although the inclusion criteria in the present study had tumors <2 cm, some were found to be larger intraoperatively (up to 4 cm), but still were treated with PCNSS. A single patient with multifocal tumors was also subjected to this approach. As per the EAU guidelines, RNU should have been performed in these cases as these are high-risk tumors. Why was RNU not performed in these patients? These patients may be at a higher risk of inadequate resection and recurrence after PCNSS. Was there any extra precaution taken concerning the management of these patients? Were these the same patients who later on developed high-grade recurrence?

Although a preoperative biopsy was not performed in this study due to technical constraints, the role of biopsy as an additional diagnostic tool is well established because it helps in risk stratification of the tumor and should be considered before planning a definitive procedure. Why the three patients who showed a high-grade tumor on PCNSS (primary diagnosis) were not offered upfront RNU? In the present study, 21.4%[3] of the patients had ipsilateral local recurrent high-grade UTUC or local lymph node metastasis occurring at 3–60 months following PCNSS. Could this be prevented by an early RNU?