A Critical Appraisal of the Value of Lymph Node Dissection at Nephroureterectomy for Upper Tract Urothelial Carcinoma

Objectives

To perform a population-based analysis of the potential staging or prognostic value (or both) of lymph node dissection (LND) in patients without nodal metastases vs no LND. In several previous reports, LND in patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy (NU) was associated with better survival relative to no LND (pN_x), even in the absence of pathologically confirmed nodal metastases (pN₀).

Methods

Within the surveillance, epidemiology, and end results database, we identified 2824 patients treated with NU for UTUC between 1988 and 2004. CSM rates after NU were graphically explored using Kaplan–Meier plots. Univariable and multivariable Cox regression models tested the effect of N₀ vs N_x stage on CSM, after adjusting for T stage, tumor grade, age, gender, primary tumor location, type, and year of surgery.

Results

The CSM-free survival rate at 5 years after NU was 81.2% and 77.8% respectively for pN₀ and pN_x patients. In univariable analyses pN_x vs pN₀ status was not associated with worse survival (HR: 1.19; P = .09). After adjustment for all covariates, pN_x vs pN₀ status still failed to achieve independent predictor status (HR: 0.99; P = .9).

Conclusions

We found no survival benefit related to the performance of LND in pN₀ patients, relative to pN_x patients. Lack of standardized criteria for patients' selection for LND and for pathological lymph node specimen evaluation represents some of the explanation for the observed discrepancy between the current finding and previous findings.