Pattern of lymph node recurrence in upper tract urothelial carcinoma after lymph node dissection: Recommendations for optimizing the area of lymph node dissection

Purpose The implementation of standardized lymph node dissection (LND) remains limited in real-world practice. We aimed to analyze the prognosis and recurrence patterns of UTUC patients who underwent LND in real-world practice, with the goal of optimizing the current LND template. Methods This study included 125 UTUC patients who underwent radical nephroureterectomy (RNU) with LND at Peking University First Hospital between January 2010 and March 2022. LND performance and recurrence sites were mapped and stratified by primary tumor locations. Cox proportional hazard models were used to analyze the factors associated with recurrence and survival outcomes. Results The median follow-up duration was 55 months. Thirty-two (25.6%) patients experienced local lymph node (LN) recurrence. The para-aortic lymph node (PAN) region was the most frequently involved area (81.3%) and the left para-aortic (LPA) area was the predominant location (68.8%). Among recurrent lower ureteral tumor patients, the recurrence rate in the common iliac region (78.6%) and PAN region (71.4%) remained high. For right-sided UTUC, high recurrence rates were observed in the LPA (56.3%) and aortocaval (AC) (43.8%). Forty-four patients (35.2%) died, and the removal of ≥ 8 LNs was significantly associated with lower local recurrence rates and improved overall survival (OS). Conclusion The removal of ≥ 8 LNs was the only factor associated with improved OS. Recurrence patterns indicated the inadequacy of the conventional LND template. For distal UTUC, the extension of LND to the PAN region and meticulous dissection in the common iliac area are recommended. The LPA region dissection was overlooked in right-sided UTUC.