Longitudinal Risk of Upper Tract Recurrence Following Radical Cystectomy for Urothelial Cancer and the Potential Implications for Long-Term Surveillance

Purpose: The defined risk of upper tract recurrence in published series ranges from 2% to 6%, with most recurrence reported within 2 to 3 years of surgery. However, these recurrence rates are based on statistical methodology that does not take censoring into account. We used landmark time analysis to determine whether the risk of upper tract recurrence changes over time. Materials and Methods: We present a retrospective institutional review board approved review of 1,329 patients who underwent radical cystectomy from 1990 to 2004. Upper tract recurrence was defined as any radiographic, endoscopic or pathologically proven recurrence in the kidney or ureter. Cumulative incidence of upper tract recurrence was estimated by accounting for death without recurrence as a competing risk. Landmark analyses were used to estimate the probability of upper tract recurrence within the next 3 years if recurrence-free at various times after surgery. Results: A total of 80 patients experienced upper tract recurrence. Median followup for patients alive and recurrence-free was 38 months. The 3 and 5-year cumulative incidence of upper tract recurrence was 4% (95% CI 3, 6) and 7% (95% CI 5, 8), respectively. Landmark time analysis showed the 3-year cumulative incidence of upper tract recurrence remained 4% to 6% even at 4 years after radical cystectomy. Any ureteral involvement at radical cystectomy (including carcinoma in situ) portends a significantly higher risk of upper tract recurrence. Conclusions: The incidence for upper tract recurrence was 4% at 3 years and 7% at 5 years. However, the 3-year risk of upper tract recurrence remained around 4% to 6% at any point measured up to 4 years after radical cystectomy and, therefore, did not change over time. This indicates the critical importance of long-term vigilance for upper tract recurrence following radical cystectomy.