Surgical management of the distal ureter during radical nephroureterectomy is an independent predictor of oncological outcomes: Results of a current series and a review of the literature

Objective: To evaluate the effect of distal ureter management on oncological outcomes in patients with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. Methods and materials: Retrospective review of patient records and operative reports was conducted on 122 patients who underwent RNU. Data were compared between 2 groups using substratification by distal ureter management (transvesical bladder cuff [TVBC]) vs. no TVBC). Results: Mean patient age was 69.0 years and 63.1% were male. Median follow-up was 32.0 months. Most patients (n = 76, 62.3%) received a TVBC and 46 (37.7%) patients received no TVBC during RNU. There were no significant differences in clinicopathological variables between both groups except for a higher rate of lymphadenectomy during surgery in the TVBC group (38.2% vs. 15.2%). On multivariate analysis, intravesical recurrence (IVR) was not affected by distal ureter management but was affected by tumor multifocality (hazard ratio [HR] = 2.2; 95% confidence interval [CI], 1.2-4.0; P = 0.013). However, non-IVR-free survival (non-IVR FS) and cancer-specific survival (CSS) were independently influenced by T stage (HR = 4.9; 95% CI, 1.5-16.3; P = 0.010 for non-IVR FS and HR = 6.3; 95% CI, 1.7-23.1; P = 0.005 for CSS) and management of the distal ureter (HR = 3.2; 95% CI, 1.3-7.6; P = 0.010 for non-IVR FS and HR = 3.4; 95% CI, 1.3-8.8; P = 0.010 for CSS). Conclusions: In our study, surgical management of the distal ureter without excision of a TVBC resulted in significantly worse non-IVR FS and CSS but had no influence on IVR. This is hypothesis generating and supports further prospective study as to standardization of BC resection during RNU.