Current guidelines recommend performing a lymph node dissection (LND) at the time of radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC), particularly for those with high-risk disease features [1]. While survival benefits of a LND remain unclear [2,3], this procedure has important staging implications, given level 1 evidence from the POUT trial supporting the use of platinum-based combination chemotherapy in the adjuvant setting for patients with locally advanced UTUC [4].

In contrast to adjuvant chemotherapy, the survival benefit and exact indications for neoadjuvant chemotherapy (NAC) prior to RNU remain less clear. Current evidence is limited to single-arm, phase II trials that have demonstrated promising survival outcomes [[5], [6], [7], [8]]. Randomized trials of NAC vs. no NAC prior to RNU remain unavailable, likely secondary to real-world challenges with trial recruitment of eligible UTUC patients.

The optimal sequencing of neoadjuvant and adjuvant therapy in UTUC patients undergoing RNU is unknown. Evaluating the outcomes of these patients following a RNU, stratified by prior NAC treatment and pathologic status (e.g., [y]pN+ vs. [y]pN0), as well as predictors of adverse prognosis in the post-NAC setting, is essential for tailoring risk-adapted approaches for the treatment of these high-risk patients. Prior studies have yet to evaluate recurrence patterns in the post-NAC setting, which has important implications for surveillance strategies. In this multicenter study, we evaluated the survival outcomes, including predictors of adverse prognosis, and recurrence patterns of UTUC patients undergoing a RNU + LND stratified by prior NAC and pathologic nodal status.