Impact of neoadjuvant chemotherapy on perioperative outcomes following nephroureterectomy.

Abstract

697 Background: Upper tract urothelial carcinoma (UTUC) is a urologic malignancy for which nephroureterectomy (NU) remains a cornerstone treatment. For high-grade disease, neoadjuvant chemotherapy (NAC) is recommended and has shown survival benefit. However, NAC has been linked to increased frailty and perioperative complications in other malignancies. Limited data exist regarding its impact on perioperative outcomes in patients undergoing NU. We evaluated perioperative outcomes in patients receiving NAC versus NU alone using a large, multi-institutional database. Methods: We analyzed patients undergoing NU for UTUC from 2019–2023, identified through the ACS-NSQIP database using relevant CPT codes. Patients were stratified by NAC receipt prior to NU. Baseline demographics, comorbidities, and 30-day perioperative outcomes were compared using chi-square, Fisher’s exact, and Welch’s t-test. Primary outcomes included 30-day major/minor complications, length of stay (LOS), readmission, reoperation, and mortality. Results: Of 2,872 patients, 300 (10%) received NAC and 2,572 (90%) underwent NU alone. Groups were similar in comorbidities with minor differences in age, race, and BMI. Complication rates were comparable: minor (21% vs 24%, p=0.36) and major (11% vs 12%, p=0.76). The NAC group had longer operative time (256 ± 91 vs 228 ± 89 min, p<0.001) and higher lymphocele rates (4% vs 2%, p=0.003) but were more likely to undergo lymph node dissection (68% vs 43%). No significant differences were seen in LOS (3.5 vs 3.6 days, p=0.63), readmission (9% vs 8%, p=0.62), reoperation (3% vs 3%, p=0.66), or mortality (0% vs 1%, p=0.39). Patients receiving NAC had higher pathologic complete response rates (pT0: 8% vs 4%, p=0.02). Conclusions: In this multi-institutional analysis—representing the largest to date—patients receiving NAC had comparable perioperative outcomes to those undergoing NU alone. NAC was also associated with higher pT0 rates on final pathology. These findings suggest NAC does not worsen perioperative outcomes or significantly contribute to preoperative frailty, while providing benefit in disease downstaging. This analysis supports NAC’s safety for use in appropriately selected patients with high-grade UTUC undergoing NU. 30-day patient outcomes. NU AloneN = 2572 NU with NACN = 300 p-value Minor Complications 550 (21.38%) 71 (23.67%) 0.3635 Bleeding Requiring Transfusion 165 (6.42%) 25 (8.33%) 0.2059 Lymphocele 46 (1.79%) 13 (4.33%) 0.0033* Urinary Leak 37 (1.44%) 1 (0.33%) 0.1129 Major Complications 285 (11.08%) 35 (11.67%) 0.7602 Return to operating room 66 (2.57%) 9 (3%) 0.6556 Readmission 210 (8.16%) 27 (9%) 0.6188 Death 15 (0.58%) 0 (0%) 0.3914 Length of Total Hospital Stay (days) 3.63 ± 3.45 3.47 ± 5.75 0.6259 *Statistically significant.