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Does Hydronephrosis on Preoperative Axial CT Imaging Predict Worse Outcomes for Patients Undergoing Nephroureterectomy for Upper-Tract Urothelial Carcinoma?
Casey K. Ng, Jay D. Raman, Shahrokh F. Shariat, Steven M. Lucas, Aditya Bagrodia, Yair Lotan, and Douglas S. Scherr
Introduction and objective: Hydronephrosis at the time of diagnosis of bladder cancer is associated with advanced tumors and is a predictor of poor outcome. There is limited information, however, addressing whether a similar relationship exists for upper-tract urothelial carcinoma (UTUC). Hydronephrosis in patients with UTUC can be attributed to luminal obstruction, intramural invasion, or extrinsic compression.. This study investigated the prognostic impact of hydronephrosis found on preoperative axial imaging on clinical outcomes after radical nephroureterectomy.
Methods: The records for 106 patients with UTUC who underwent radical nephroureterectomy at two medical centers were reviewed. Preoperative computed tomography (CT) images were evaluated for ipsilateral hydronephrosis by radiologists blinded to clinical outcomes. Association of hydronephrosis with pathologic features and clinical outcomes after surgery was assessed.
Results: 67 men and 39 women with a median age of 69 years (range, 36 to 90) were evaluated. 39 patients (37%) had hydronephrosis. Of the 39 patients with preoperative hydronephrosis, 35% had ureteral tumors, 27% had multifocal disease, 44% had high grade disease, 19% had lymphovascular invasion (LVI), and 3% had lymph node (LN) metastasis. 43% of patients with hydronephrosis experienced disease recurrence, 18% developed metastasis, and 12% died of their cancer at a median follow-up of 47 months (range, 1 to 164).The presence of hydronephrosis was associated with advanced pathologic stage (p=0.03), lymph node involvement (p=0.05), and disease in the ureter (versus renal pelvis) (0=0.01). Hydronephrosis was a predictor of non-organ confined disease on final pathology (hazard ratio [HR] 3.7, p=0.01). On preoperative multivariable analyses controlling for tumor location, age and gender, hydronephrosis was independently associated with cancer metastasis (HR 3.5, p=0.009) and cancer-specific death (HR 5.2, p=0.009). On postoperative multivariable analysis that adjusted for the effects of pathologic stage and grade, LVI, and LN status, preoperative hydronephrosis was not associated with any of the outcomes. (Why include post operative factors. It is irrelevant to this anlysis?)
Conclusions: Preoperative hydronephrosis on axial imaging is associated with features of aggressive disease and predicts advanced pathologic stage. More importantly, preoperative hydronephrosis is an independent predictor of the likelihood of developing metastasis and death from UTUC. Hydronephrosis on axial imaging can be a valuable prognostic tool for preoperative planning (i.e., lymphadenectomy) and patient counseling regarding outcomes.