Optimal Cystoscopic Surveillance Schedule Following Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma.

Background: Upper tract urothelial carcinoma (UTUC) has shown an increasing incidence, with intravesical recurrence (IVR) being a common postoperative challenge following radical nephroureterectomy. Although current guidelines recommend cystoscopic surveillance based on risk stratification, these recommendations are weak and may not adequately address IVR-specific risk factors or optimal surveillance intervals.

Methods: We retrospectively analyzed 700 patients who underwent radical nephroureterectomy between 2012 and 2021. Risk factors for IVR were identified using Cox proportional hazards regression models, and optimal cystoscopic intervals were evaluated through hypothetical surveillance models. Gap risk ratios were calculated to assess the risk of delayed IVR detection, stratified by the presence or absence of identified risk factors.

Results: The median follow-up duration was 28 months, and IVR occurred in 38.0% of patients. Significant risk factors included a history of bladder cancer, positive voided cytology, and preoperative ureteroscopy. Kaplan-Meier curves revealed significantly worse IVR-free survival in patients with 1 or more risk factors (P < .001). Gap risk ratio analysis supported frequent surveillance during the first postoperative year, with tailored intervals thereafter. For patients without risk factors, surveillance every 3 months during the first year, every 6 months during the second year, and annually thereafter was optimal. For patients with risk factors, surveillance every 3 months during the first year, every 6 months for the next 2 years, and annually thereafter was recommended.

Conclusion: Tailored cystoscopic surveillance schedules based on IVR risk factors optimize recurrence detection while minimizing procedural burden. These findings provide an evidence-based framework for individualized surveillance strategies in patients with UTUC following nephroureterectomy.