External validation of current quality care metrics after radical nephroureterectomy

Objectives

To externally validate the tetrafecta and pentafecta frameworks for assessing the quality of radical nephroureterectomy (RNU) and their correlation with oncological outcomes in patients with localised upper tract urothelial carcinoma (UTUC).

Patients and Methods

This retrospective study included 545 patients who underwent RNU for localised UTUC between 2012 and 2023 at eight French university hospitals and one Lebanese university hospital. Achievement of tetrafecta required four criteria to be met: negative surgical margins, complete bladder cuff excision, lymph node dissection (if indicated), and absence of recurrence within 12 months. Pentafecta consisted of the same criteria, plus no major complications or haematological events. Oncological outcomes assessed included intravesical recurrence-free survival (IVRFS), recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS). Kaplan–Meier analyses, Cox regression, and calibration plots were used to evaluate the predictive performance of the frameworks for 3-year outcomes.

Results

A total of 29.5% of our cohort achieved tetrafecta and 34.5% achieved pentafecta. Patients meeting either of these quality care metrics demonstrated significantly improved oncological outcomes, with higher 3-year OS rates (tetrafecta: 90.1% vs 74.2%, P < 0.001; pentafecta: 89.4% vs 73.4%, P < 0.001) and RFS rates (tetrafecta: 84.5% vs 57.6%, P < 0.001; pentafecta: 83.5% vs 56%, P < 0.001). Both metrics showed high predictive accuracy for OS (area under the curve [AUC] 0.92 for tetrafecta; 0.93 for pentafecta, P = 0.41) and CSS (AUC 0.944 for tetrafecta; 0.945 for pentafecta, P = 0.6018). Pentafecta achievement was independently associated with better OS and CSS in multivariable analysis (hazard ratio [HR] 0.30, 95% confidence interval [CI] 0.16–0.55, P < 0.001 and (HR 0.24, 95% CI 0.10–0.54, P < 0.001, respectively).

Conclusion

Tetrafecta and pentafecta are reliable tools for assessing oncological outcomes after RNU in localised UTUC. Pentafecta demonstrated stronger prognostic value for OS, particularly in high-risk populations. These metrics offer a standardised framework to guide clinical decisions, evaluate surgical quality, and counsel patients about prognosis.