ENDOSCOPIC VERSUS LAPAROSCOPIC MANAGEMENT OF UPPER TRACT UROTHELIAL CARCINOMA 2061

EDITORIAL COMMENT

This report adds to the evidence that endoscopicmanagement of UTUC is an excellent alternative tonephroureterectomy in the setting of low grade ma-lignancy but is associated with inferior oncologicoutcomes in the setting of high grade malignancy.The authors attempted to limit their comparison topatients with noninvasive disease. They proposethat a greater incidence of invasive disease in theextirpative cohort in prior comparative series (refer-ences 9 to 14 in article) had biased those compari-sons against extirpative therapy. While this con-founding may well be present, their methodology

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disease with endoscopic management. It is likely

the authors’ credit, they admit as much, acknowl-edging that “a proportion of the higher grade endo-scopic cases with clinically noninvasive UTUC mayhave been under staged, which potentially biasesthis group to poorer outcomes.” Thus, this reportserves as a bookend on the spectrum of comparisons ofendoscopic and extirpative treatment of UTUC. Theoncologic efficacy of endoscopic treatment may well beoverestimated in prior reports, but I suspect that itsrelative efficacy is underestimated in this report.

J. Stuart Wolf, Jr.

likely has biased their results against endoscopy. To Ann Arbor, Michigan

It is inevitable that there will always be selectionbias to the different arms of studies comparing en-doscopic management to nephroureterectomy forseveral inherent reasons. The rare incidence of non-muscle invasive UTUC effectively precludes the re-cruitment of patients with equally matched tumorcharacteristics to both treatment arms. Endoscopicmanagement naturally selects patients with favor-able tumor characteristics (such as small tumor size,unifocality, low grade and stage) as it is principallyan ablative rather than extirpative form of surgery.However, the study outcomes do underscore the in-herent dangers of treating patients with high grade

that the poorer outcomes reflect the limitations inthe efficacy of ablative surgery and the inevitablerisk of under staging in patients with higher gradedisease.

Any study aiming to compare endoscopic manage-ment to NU for purely clinically staged noninvasiveUTUC, with matched tumor characteristics wouldrequire a long recruitment process and a multi-center collaborative effort as currently only 6 insti-tutions have reported endoscopic experience beyond50 patients. It is possible that prospectively de-signed, multicenter collaborative studies will, in thefuture, define the outcomes of endoscopic manage-

ment more accurately.