Re: How to Manage Patients with Suspected Upper Tract Urothelial Carcinoma in the Pandemic of COVID-19?

Lee HY, Chan EOT, Li CC, et al

Urol Oncol 2021;39:733.e11–6

Experts’ summary:

The authors hypothesize that delayed surgery (as often imposed during the COVID-19 pandemic) may influence the survival of patients with upper tract urothelial carcinoma (UTUC). Cases of histologically proven UTUC were dichotomized according to time from first consultation to radical nephroureterectomy (RNU), with 432 patients in the early RNU group (≤3 mo) and 168 in the delayed RNU group (>3 mo). The aim of the study was to determine the impact of a delay and whether it is feasible to proceed directly to RNU without prior ureteroscopy (URS) to expedite UTUC management. The early RNU group experienced better overall survival. Larger tumor size, multifocality, ≥T2 disease, and positive lymph nodes predicted a poorer survival outcome. The presence of three pre-URS factors (gross hematuria, abnormal cytology, and changes on a computed tomography scan) without URS achieved an area under the receiver operating characteristic curve (AUC) of 0.809, similar to the AUC of 0.851 when URS was performed. Any two of three factors without URS achieved an AUC of over 0.7. The authors concluded that delaying RNU for more than 3 mo should be avoided if possible, while the presence of at least two of the factors mentioned means that URS before proceeding to RNU can be avoided.

Experts’ comments:

The COVID-19 pandemic required major changes to health care standards and priorities all over the world. Shortening of hospital stays for non-COVID-19 patients was the paramount approach while significant resources were being diverted to COVID-19 prevention or treatment.

The authors chose a 3-mo cutoff to stratify early and delayed RNU groups, inspired by similar bladder cancer studies. A patient with UTUC usually requires two surgical procedures (URS and RNU). The authors focused on identifying factors predictive of survival outcome with the aim of deeming URS before RNU unnecessary for a subset of patients and providing an opportunity to reduce hospital stays during the COVID-19 pandemic. However, some patients who do not undergo URS may miss the opportunity to benefit from a conservative UTUC treatment. The proportion of UTUC cases for which an elective conservative therapeutic approach is feasible is increasing [1], an option that also facilitates reductions in hospital stays. However, URS before RNU may increase the risk of bladder recurrence despite technical precautions intended to avoid tumor spillage [2], although this perspective is not entirely supported by the available literature data [3]. Other limitations of the study, as acknowledged by the authors, are its retrospective nature and the older 1973 World Health Organization tumor grading classification in relation to the 2000–2019 time period for the cohort of UTUC patients.

The authors have nothing to disclose.