The role of surgical resection of the primary tumor in metastatic upper tract urothelial carcinoma: a systematic review and meta-analysis.

Purpose of review: To evaluate the role of extirpative surgery for the primary tumor in metastatic upper tract urothelial carcinoma (mUTUC).

Recent findings: The PubMed, Web of Science, and Cochrane Library were searched on July 2024 to identify relevant studies according to the Preferred Reporting Items for Systematic Review (PRISMA) statement. Studies were eligible for analysis if they compared oncologic outcomes between mUTUC patients who underwent surgical resection of the primary tumor and patients who did not. Cancer-specific survival (CSS) and overall survival (OS) were assessed using multivariate logistic regression analyses. We identified 2686 reports, of which 11 articles comprising 12 833 records were selected for this systematic review. Eight and three studies used Surveillance Epidemiology and End Results (SEER) and National Cancer Database (NCDB) databases, respectively. Surgical resection of the primary tumor was significantly associated with better CSS and OS in patients with mUTUC. Among the 5353 mUTUC patients included in our meta-analysis, radical nephroureterectomy (RNU) was independently associated with better OS with a pooled hazard ratio (HR) of 0.62 [95% confidence interval (CI) 0.54-0.72, P  < 0.05]. Subgroup analyses of studies restricted to mUTUC patients with distant lymph node metastasis ( n  = 1372) revealed RNU to be independently associated with better OS with pooled HR: 0.44 (95% CI 0.28-0.67, P  < 0.05) together with systemic chemotherapy, primary tumor site in the ureter, lower T stage, and no locoregional lymph node involvement.

Summary: Surgical resection of the primary tumor offers oncologic survival benefits in select patients with mUTUC. However, in the absence of data from prospective randomized studies, it is essential to evaluate each patient individually as part of a collaborative multidisciplinary shared decision working with the patient.