Risk stratification of upper tract urothelial carcinoma (UC) is central to current clinical guidelines on postoperative surveillance after management with radical nephroureterectomy (RNU). While low-grade upper tract urothelial carcinoma (LG-UTUC) is generally classified as low risk and lacks significant association with cancer-specific mortality, urothelial recurrence in the bladder is not uncommon. Here we describe recurrence patterns and predictive risk factors for urothelial recurrence after RNU for LG-UTUC in order to improve surveillance strategies and treatment outcomes.


Retrospective review of 474 RNUs at our institution from February 2010 to August 2021 identified 87 patients with LG-UTUC. Clinical, pathologic, recurrence, and survival data were obtained. Descriptive statistics, Kaplan-Meier survival curves, Mantel-Cox log rank testing, and logistic regression modeling were utilized to examine the cohort and compare risk factors for any and early recurrence of urothelial malignancy following RNU.


Among 87 RNUs for LG-UTUC, mean age at surgery was 71.8 years, and most patients were male (74.7%), white (90.8%), and current/former smokers (90.9%). 50.6% had history of UC of the bladder. Median overall survival (OS) was 97.9 months (mos) (Figure 1). Thirty-nine patients (44.8%) with LG-UTUC experienced any UC recurrence over a mean follow up of 34.0 mos. Recurrence was diagnosed at median 7.5 mos post-RNU, and median recurrence-free survival was 14.4 mos. 69.2% of recurrences were low-grade and all but two initially recurred in the bladder. Multivariable analysis of demographics, surgical factors, and tumor characteristics demonstrated that current smoking (OR 4.0, p=0.04) and tumor multifocality (OR 3.5, p=0.04) were associated with recurrence at any time point (Table 1). Tumor multifocality was also significantly associated with early urothelial recurrence within 6 months of RNU on unadjusted analysis.


LG-UTUC is at risk of recurrence in the bladder; however, development of metastatic disease and cancer-related mortality is very rare after definitive management with RNU. Current smoking and tumor multifocality are independently associated with recurrence of UC after RNU and may inform surveillance strategies.

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