EURURO Vol. 72 No. 3

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LUTS, specifically storage symptoms, ncreases the risk of
falling and fractures [3]. In this population, falls are the
leading cause of injury and death [4]. Suffering a fall or
fracture increases one’s morbidity, with approximately 33%
of patients not surviving beyond 1 yr [5].
As leaders in men’s health, we must take action on the
potential complications of LUTS and assess fall risk. We
must ask about the patient’s history and risk of falls to
initiate a comprehensive plan of care. Standard of care
metrics do not account for this association with LUTS and
we must protect these vulnerable patients. Patients come to
us seeking guidance, knowing we have their best interest at
heart, and a failure to screen for falls would be a grave
disservice.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
[2]
[3]
.
[4] Web-based Injury Statistics Query and Reporting System. 2017
[5]
.
Dominique Thomas, Bilal Chughtai*
Department of Urology, Weill Cornell Medicine, New York-Presbyterian,
New York, NY, USA
*Corresponding author. Weill Cornell Medicine, Department of Urology,
Department of Obstetrics and Gynecology, 425 East 61st Street,
12th Floor, New York, NY 10065, USA.
E-mail address: (B. Chughtai).
# 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Effectiveness of Adjuvant Chemotherapy After
Radical Nephroureterectomy for Locally Advanced and/
or Positive Regional Lymph Node Upper Tract Urothelial
Carcinoma
Seisen T, Krasnow RE, Bellmunt J, et al
J Clin Oncol 2017;35:852–60
Experts’ summary:
Seisen and colleagues evaluated the benefit associated with
adjuvant chemotherapy (ACT) after radical nephroureterec-
tomy (RNU) in locally advanced urothelial carcinoma of the
upper urinary tract (UTUC) [1]. The study included
3253 patients from the National Cancer Data Base treated
between 2004 and 2012 who received ACT (n = 762; 23.4%) or
observation (n = 2491; 76.6%) after RNU. Inverse probability of
treatment weighting (IPTW)–adjusted Kaplan-Meier curves
showed greater median overall survival (OS) of 47.4 mo in the
adjuvant therapy group versus 35.8 mo in the observation
group (p < 0.001). The 5-yr IPTW-adjusted OS rate was 43.90%
versus 35.85%. Moreover, the OS benefit was consistent across
all subgroups examined (all p < 0.05), with no significant
heterogeneity of treatment effect detected.
Experts’ comments:
The intention to administer perioperative chemotherapy for
patients with UTUC is based on its capability to potentially
eradicate micrometastases and improve survival after RNU.
However, the major limitation thus far is a lack of results from
dedicated prospective studies for patients with UTUC, in
particular in the perioperative context. A randomized phase
3 trial of ACT versus surveillance, promoted by the UK Insti-
tute of Cancer Research, is currently recruiting patients, and
results are awaited (NCT01993979).
Conversely, neoadjuvant chemotherapy (NAC) is not
supported by a sufficient level of evidence to recommend it
in clinical practice. Shortcomings of clinical staging are an
issue for NAC, and shared criteria for selecting the patients
most suitable for NAC are lacking. Clinicians might
generally feel more comfortable administering ACT with
full pathological evaluation of an RNU specimen to avoid
both overtreatment and delay to surgery.
While the study be Seisen et al is of great interest and the
authors have to be congratulated for conducting it,
especially as the rarity of UTUC makes prospective trials
even harder than for bladder cancer, some limitations have
to be underlined.
First, the lack of information on the type of chemotherapy
and regimen used (ie, cisplatin vs carboplatin vs non-
platinum–based chemotherapy) does not improve the lack of
knowledge on adequate treatment for use in daily practice.
Second, lymph node dissection for evaluation or treatment
was at the surgeon’s discretion. Indeed, the clinical benefit
and adequate anatomical templates for lymph node dissec-
tion concomitant with RNU are still an open debate [2]. Thus,
selection bias may have occurred regarding which patients
had lymph node dissection (or not) and towhat extent. Third,
although the authors applied advanced statistical methods to
correct for possible confounders between the ACT and
observation groups, many other confounders are unaccount-
ed for in such retrospective analyses. In particular, the role of
pathological factors such as the presence of vascular invasion
may have impacted patient outcomes in the two groups
[3]. Fourth, there is the unanswered question of the right
timing for ACT administration: immediately after surgery or
delayed until the time of relapse. This question could not be
addressed because patients who received chemotherapy
>90 d after surgery were excluded. This is an important
question, as ACT in muscle-invasive bladder cancer did not
yield a significant improvement in OS compared to delayed
chemotherapy at the time of relapse (EORTC trial 30994),
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