UROLOGICAL ONCOLOGY

Hydronephrosis as a Prognostic Marker in Bladder Cancer in a Cystectomy-Only Series
Bartsch GC, Kuefer R, Gschwend JE, de Petriconi R, Hautmann RE, Volkmer BG
Department of Urology, Faculty of Medicine, University of Ulm, Ulm, Germany
Eur Urol. 2007; 51: 690-7; discussion 697-8

• Objectives: Hydronephrosis in patients with bladder cancer is caused by tumour at the ureteral orifice, secondary ureteral tumours, intramural or extravesical tumour infiltration, or compression of the ureter. This study investigated the prognostic impact of hydronephrosis in bladder cancer.
• Methods: A series of 788 patients were treated with radical cystectomy with curative intent for transitional cell carcinoma of the bladder without neoadjuvant/adjuvant radiotherapy/chemotherapy between January 1986 and September 2003. All patients had a complete follow-up until death or until the study’s end date. Survival rates were calculated using the Kaplan-Meier method. A multivariate analysis with a Cox regression model was performed with respect to potential influencing factors.
• Results: A total of 108 patients (13.7%) had unilateral and 25 patients (3.2%) had bilateral hydronephrosis. The rate of organ-confined tumours was significantly higher in patients without hydronephrosis (67.9% vs. 37.6%; p<0.001). Forty-three (32.3%) of the 133 hydronephrotic patients had a tumour involving the ureteral orifice. In this group the rate of organ-confined tumours was significantly higher than in the other patients with hydronephrosis (53.5% vs. 30.0%; p=0.009). In the multivariate analysis, preoperative hydronephrosis was determined as an independent prognostic marker for recurrence-free survival besides the pT classification and lymph node status (p=0.0015). The etiology of hydronephrosis did not affect the tumour-specific survival.
• Conclusions: Hydronephrosis at the time of diagnosis of bladder cancer is associated with a high probability of advanced tumours. It is an independent prognostic factor for recurrence-free survival.
  
  
• Editorial Comment
  The question if patients with concomitant hydronephrosis and bladder cancer have inferior prognosis is a matter of debate since long. Here, the authors stratify their patients into two cohorts, hydronephrosis without tumor at the ureteral orifice versus no hydronephrosis or hydronephrosis with tumor at the ureteral orifice. This stratification increases significantly the prognostic impact of hydronephrosis. According to their results, a patient with hydronephrosis without tumor at the orifice has a 70% risk of having non-organ confined disease and a 40% risk of lymph node metastases, in contrast to patients with visible tumor at the orifice having risks at 41.7% and 19.4%, respectively. This translates into different tumor-specific survival rates.
  Thus, hydronephrosis without visible tumor at the orifice is a very ominous prognostic factor.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany