A Commentary on “Comparative outcomes and prognosis in patients with ureteral upper tract urothelial carcinoma undergoing segmental ureterectomy versus radical nephroureterectomy: a multicenter cohort study”

Dear Editor, We read with great interest the article entitled “Comparative outcomes and prognosis in patients with ureteral upper tract urothelial carcinoma undergoing segmental ureterectomy versus radical nephroureterectomy: a multicenter cohort study1” published in the International Journal of Surgery. We would like to compliment the authors for this well designed and impactful clinical study. Using one of the largest multicenter datasets available, this study offers strong evidence in support of segmental ureterectomy (SU) as an option for achieving oncologic results equivalent to radical nephroureterectomy (RNU) with the added benefit of preserving renal function. These results are especially timely and clinically applicable. In an era increasingly emphasizing organ preservation, quality of life, and personalized cancer treatment, robust data supporting kidney-sparing approaches are of substantial value. The authors’ work meaningfully contributes to the growing body of literature suggesting that SU may represent a safe and effective alternative to RNU in appropriately selected patients with ureteral upper tract urothelial carcinoma (UTUC). We largely agree with the authors’ conclusions and believe that the study provides a strong foundation for expanding the role of SU in clinical practice. With this in mind, we would like to offer a few minor considerations that may further enhance the interpretability and clinical applicability of the results. First, tumor size is an important prognostic variable for UTUC that should be explicitly considered as the baseline feature. Recent systematic review and meta-analysis comprising over 32 000 patients showed that increased tumor size was significantly related to poor OS and CSS, recurrence-free survival, and intravesical recurrence in UTUC irrespective of the treatment modality2. Because of its known prognostic significance as well as potential impact on choice of surgery, including tumor size in baseline comparison or multivariable adjustment could help minimize residual confounding even more and improve validity for comparing SU with RNU. Second, although muscle-invasive status was included among baseline variables, the omission of formal tumor-node-metastasis (TNM) staging deserves consideration. Pathological TNM stage has been consistently identified as an independent predictor of cancer-specific mortality in non-metastatic UTUC patients undergoing RNU3. Including TNM stage as either a baseline or adjusted variable may provide a more granular assessment of tumor burden and biological aggressiveness, thus providing better risk adjustment and lessening the effect of confounding variables in comparing oncologic outcomes for different surgical techniques. Third, due to its retrospective design, using a risk-stratified comparator approach might add additional levels of clinical clarity. Comparing SU vs RNU in cohorts stratified by known preoperative and pathologic risk classifications can shed light on whether the benefit from nephron-sparing approaches is universal across risk strata or limited to certain select subsets. These analyses may also be used in direct clinical practice, helping surgeons determine which patients are most likely to achieve both optimal cancer control and kidney retention. In addition to these considerations, we would like to gently draw attention to a minor issue related to data presentation. As shown in Figure 3D, the labels for SU and RNU seem to be inverted. Although it should have no impact on the main conclusion of the work, its clarification or modification could prevent some possible confusion in the reader’s mind as well as allow a better coherence with both graphical and textual results. In conclusion, this study offers valuable evidence on the oncologic safety of SU in select patients with ureteral UTUC. Adding to the list of potential prognostic variables for SU including tumor size and TNM stage, including risk-stratified comparisons, could further bolster these findings and support better, more personalized surgical decisions. We appreciate the authors’ contribution to this evolving field and hope these comments will be received in the constructive spirit intended. This study is compliant with the TITAN Guidelines4.