# Radical Nephroureterectomy Pentafecta as a Predictor of Upper Tract Urothelial Carcinoma Outcomes Following Radical Surgery

## TL;DR

This study shows that meeting five surgical quality criteria after kidney surgery for upper urinary tract cancer is linked to better survival and lower recurrence rates.

## Contribution

The study validates a pentafecta of surgical quality metrics as a predictor of improved outcomes in upper tract urothelial carcinoma patients.

## Key findings

- Pentafecta achievement was associated with a 41.4% lower risk of death and a 70.9% lower risk of recurrence.
- Only pentafecta achievement and advanced T stage were independent predictors of survival outcomes.
- Tumor location, multifocality, and open surgery were linked to lower pentafecta achievement rates.

## Abstract

Combined criteria have been used in many facets of urologic surgical care in the management of urological cancer. We aimed to validate the prognostic ability of a pentafecta related to the outcomes of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

Data were obtained from the Clinical Research Office of the Endourology Society Urothelial Carcinomas of the Upper Tract (CROES-UTUC) registry, a prospective multinational database. Non-metastatic UTUC patients treated with RNU were included. We adopted a pentafecta criteria of (1) negative surgical margin; (2) en bloc resection of the bladder cuff; (3) absence of major complications; (4) template-based lymph node dissection performed per European Association of Urology guidelines; and (5) absence of recurrence (urothelial and/or distant recurrence) within 12 months. Outcomes were pentafecta achievement rates and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS). Kaplan–Meier survival analyses with log-rank were performed on survival outcomes. Multivariate Cox regression was performed to identify confounders, and logistic regression was performed to identify factors that confounded the pentafecta achievement rate.

Overall, 1049 cases were analyzed, and pentafecta was achieved in 504 patients (48.0%). Baseline characteristics were comparable between those who achieved pentafecta versus those who did not. Pentafecta achievement was associated with OS advantage (hazard ratio [HR] 0.586, p = 0.024) and RFS advantage (HR 0.291, p = 0.001). Multivariate Cox regression analysis identified that only pentafecta achievement and advanced T stage were independent predictors of RFS and OS. A ureteric location (compared with pelvicalyceal tumor) (odds ratio [OR] 0.424, p = 0.002), multifocality (OR 0.191, p < 0.001) and open RNU (OR 0.661, p = 0.010) were predictors of pentafecta non-achievement.

We validated a pentafecta that gauged surgical quality for RNU. Quality-of-care metrics should be promoted to unify surgical outcomes in UTUC management.