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 (pN(0)). 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 N(0) 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 pN(0) and pN(x) patients. In univariable analyses pN(x) vs pN(0) status was not associated with worse survival (HR: 1.19; P = .09). After adjustment for all covariates, pN(x) vs pN(0) 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 pN(0) 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.