Comparative outcomes of radical nephroureterectomy and kidney-sparing surgery in the treatment of high-grade upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) can be managed via radical nephroureterectomy or kidney-sparing surgery. Unfortunately, there is a paucity of data comparing radical vs. kidney-sparing management for high-grade UTUC. This study compares outcomes of radical nephroureterectomy to kidney-sparing surgery for high-grade UTUC. We retrospectively reviewed all patients with > 1-year follow-up treated for high-grade UTUC at our institution from 2015 to 2021. Oncologic and clinical outcomes were recorded. Procedure-related burden was analyzed as total procedures under anesthesia, anesthesia time, days hospitalized, and estimated cost of care. We identified 47 patients treated with radical nephroureterectomy and 16 with kidney-sparing surgery, including 1 managed via segmental ureterectomy, 14 with ureteroscopy and ablation, and 1 percutaneously. Survival outcomes, including 5-year overall survival, 3-year metastasis-free survival, and 3-year recurrence-free survival, were similar between cohorts. Patients managed with radical nephroureterectomy experienced fewer procedures but more severe perioperative complications than those treated with kidney-sparing surgery -2.1 ± 1.7 procedures vs. 3.3 ± 1.8 procedures (P = 0.037) and 0.4 ± 0.6 vs. 0 severe complications per patient, respectively (P = 0.047). Total anesthesia time and days hospitalized for radical nephroureterectomy were similar to kidney-sparing surgery at 477 ± 184 minutes vs. 377 ± 216 minutes (P = 0.13) and 6.7 ± 4.5 days vs. 5.5 ± 4.6 days, respectively (P = 0.36). Patients treated with radical nephroureterectomy experienced a greater median in-network cost of care than kidney-sparing surgery at $9,257 (IQR $7,386-$12,550) vs. $5,789 (IQR $4,833-$7,069), respectively (P = 0.009). Average changes in GFR were -21.1 mL/min/1.73 m² and -6.8 mL/min/1.73 m² for radical nephroureterectomy and kidney-sparing surgery, respectively (P = 0.11). At 2 years after surgery, 97.1% of patients who underwent radical nephroureterectomy and 100.0% who underwent kidney-sparing surgery experienced a GFR decline < 10 mL/min/1.73 m² (P = 0.12). Oncologic and clinical outcomes were similar in this select cohort of patients with high-grade UTUC treated with kidney-sparing surgery or radical nephroureterectomy. Patients treated with kidney-sparing surgery endured a greater procedural load than radical nephroureterectomy but at reduced in-network cost and with fewer severe complications. Larger datasets are needed to further evaluate outcomes and treatment burdens of radical nephroureterectomy vs. kidney-sparing surgery as high-grade UTUC treatment.