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European Urology
Volume 56, issue 1, pages 1-236, July 2009Urothelial Cancer
Reply from Authors re: Evangelos Liatsikos, Panagiotis Kallidonis. Laparoscopic or Open Nephroureterectomy? Which is the More Efficient Way to go? Eur Urol 2009;56:10–12
Hendrik Isbarn a b, Umberto Capitanio a c, Shahrokh F. Shariat a d, Pierre I. Karakiewicz a 
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Published online 3 May 2009, pages 12 - 13
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Refers to article:
Comparison of Oncologic Outcomes for Open and Laparoscopic Nephroureterectomy: A Multi-Institutional Analysis of 1249 Cases
Accepted 11 March 2009
July 2009 (Vol. 56, Issue 1, pages 1 - 9)
Refers to article:
Laparoscopic or Open Nephroureterectomy: Which Is the More Efficient Way to Go?
July 2009 (Vol. 56, Issue 1, pages 10 - 12)
Article Outline
The outcomes of upper urinary tract urothelial carcinoma (UTUC) are relatively poorly explored. Three types of databases may be used to better elucidate the effect of risk factors and the impact of various therapeutic modalities: randomized controlled trials (RCTs), multi-institutional case series [1], [2], [3], and [4], and population-based registries [5].
RCTs are ideal for assessing therapeutic alternatives. Unfortunately, RCTs are virtually nonexistent for UTUC; therefore, it is doubtful that multi-institutional, randomized trials will provide information regarding most bias-free relative efficacy of available treatment options for UTUC within a short or intermediate time frame. Moreover, the applicability of the findings from RCTs may not be ideal in the general population. The findings of an RCT comparing open nephroureterectomy (ONU) and laparoscopic nephroureterectomy (LNU) at high-volume tertiary-care referral centers, for example, may not be applicable in the community or even in lower volume, less specialized institutions.
To circumvent this limitation, several investigators, including the Upper Tract Urothelial Carcinoma Collaboration, relied on multi-institutional databases [1], [2], [3], and [4]. The current study by Capitanio et al [2], which specifically addressed the efficacy of ONU versus LNU, represents an example of a large-scale database. Despite an excellent confidence level regarding the lack of the presence of outcome differences, such databases are limited by selection criteria. Patients who are treated at tertiary-care centers that maintain clinical records and that participate in multi-institutional studies may be different from those treated in the community or even at less prestigious referral centers. Moreover, the investigation, treatment, and follow-up at such tertiary-care centers may differ from other institutions. Consequently, results derived from tertiary-care centers need to be validated in the community to ensure generalizability in that setting.
Population-based data sets, such as the Surveillance, Epidemiology, and End Results (SEER) registry, may circumvent the tertiary-care selection biases [6], [7], [8], and [9]. The amount of detail that may derived from such databases, however, cannot parallel that of either RCTs or well-designed institutional databases. Therefore, limited specificity is the price of generalizability in population-based databases. Moreover, population-based registries are rare. The SEER database allows the study of urologic tumors in the United States; however, except for the Scandinavian countries, no equivalent is yet available in Europe, Asia, or Africa. Efforts should be made to develop population-based tumor registries in other countries and on other continents. Moreover, efforts should be made to increase the amount of information available for each individual patient within the existing population-based databases.
In summary, as highlighted by Liatsikos and Kallidonis [10], Capitanio et al's study [2] suffers from several limitations for which the authors cannot control. Unfortunately, there are no alternatives for completely circumventing various selection biases that undermine the validity and the generalizability of all databases. Consequently, it is important to critically appraise the available data before directly implementing it in clinical practice.
Conflicts of interest
Pierre I. Karakiewicz is partially supported by the University of Montreal Health Center Urology Associated, Fonds de la Recherche en Santé du Québec, the University of Montreal Department Of Surgery, and the University of Montreal Health Center (CHUM) Foundation.
References
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- [2] U. Capitanio, S.F. Shariat, H. Isbarn, et al.. Comparison of oncologic outcomes for open and laparoscopic nephroureterectomy: a multi-institutional analysis of 1249 cases. Eur Urol 56 (2009) (1 - 9) Abstract, Full-text, PDF, Crossref.
- [3] E. Kikuchi, V. Margulis, P.I. Karakiewicz, et al.. Lymphovascular invasion predicts clinical outcomes in patients with node-negative upper tract urothelial carcinoma. J Clin Oncol 27 (2009) (612 - 618)
- [4] C. Bolenz, S.F. Shariat, M.I. Fernandez, et al.. Risk stratification of patients with nodal involvement in upper tract urothelial carcinoma: value of lymph-node density. BJU Int 103 (2009) (302 - 306) Crossref.
- [5] J.J. Munoz, L.M. Ellison. Upper tract urothelial neoplasms: incidence and survival during the last 2 decades. J Urol 164 (2000) (1523 - 1525)
- [6] Cloutier V, Capitanio U, Zini L, et al. Thirty-day mortality after nephrectomy: clinical implications for informed consent. Eur Urol. In press. doi:10.1016/j.eururo.2008.11.023.
- [7] U. Capitanio, L. Zini, P. Perrotte, et al.. Cytoreductive partial nephrectomy does not undermine cancer control in metastatic renal cell carcinoma: a population-based study. Urology 72 (2008) (1090 - 1095)
- [8] C. Jeldres, N. Suardi, P. Perrotte, et al.. Survival after radical prostatectomy and radiotherapy for prostate cancer: a population-based study. Can Urol Assoc J 3 (2009) (13 - 21)
- [9] L. Zini, U. Capitanio, P. Perrotte, et al.. Population-based assessment of survival after cytoreductive nephrectomy versus no surgery in patients with metastatic renal cell carcinoma. Urology 73 (2009) (342 - 346) Crossref.
- [10] E. Liatsikos, P. Kallidonis. Laparoscopic or open nephroureterectomy? Which is the more efficient way to go?. Eur Urol 56 (2009) (10 - 12) Abstract, Full-text, PDF, Crossref.
Footnotes
a Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
b Martiniclinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany
c Department of Urology, Vita-Salute San Raffaele, Milan, Italy
d Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Corresponding author. Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center (CHUM), 1058, rue St-Denis, Montréal, Québec, Canada, H2X 3J4 Tel. +1 514 890 8000 35336; Fax: +1 514 412 7363.
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