Contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy in patients with upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy: analysis of US claims on perioperative outcomes and health care costs

Introduction: New evidence indicates that minimally invasive surgery (MIS) (laparoscopic or robotic-assisted [LNU, RANU]) reaches oncologic equivalence compared with Open Radical Nephroureterectomy (ORNU) for high-risk upper-tract urothelial carcinoma (UTUC). Recently, European Association of Urology (EAU) Guidelines suggested implementing neoadjuvant chemotherapy (NAC) to standard treatment to improve oncologic outcomes of high-risk UTUC. We aimed (I) To explore contemporary trends of MIS for RNU in the United States and to compare perioperative outcomes and costs with that of ORNU. (II) To determine the trends of NAC and postoperative intravesical chemotherapy (PIC) administration for high-risk UTUC and to assess their contribution to perioperative outcomes and costs. Patients and Methods: The Optum Clinformatics® Data Mart de-identified database was queried from 2003 to 2018 to retrospectively examine patients who had undergone LNU/RANU or ORNU with or without NAC and PIC. We evaluated temporal adoption trends, complications, and health care cost analyses. We obtained descriptive statistics and utilized multivariable regression modeling to assess outcomes. Results: A total of n=492 ORNU and n=1618 LNU/RANU procedures were reviewed. The MIS approach was associated with a statistically significant lower risk of intraoperative complications (adjusted Odds Ratio [aOR], 0.48, 95%CI:0.24–0.96), risk of hospitalization costs (aOR: 0.62, 95%CI:0.49–0.78), and shorter hospital stay (aOR: 0.20, 95%CI:0.15–0.26) when compared to ORNU. Overall, adoption of NAC and PIC accounted for only n=81 and n<37 cases respectively. The implementation of NAC and higher number of cycles were associated with an increased probability of any complication rate (aOR: 2.06, 95%CI:1.26–3.36) and hospital costs (aOR: 2.12, 95%CI:1.33–3.38). Conclusion: MIS has become the approach of choice for RNU in the US. Although recommended by guidelines, neither NAC nor post-operative bladder instillation of chemotherapy has been routinely incorporated into the clinical practice of patients with UTUC.