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

To evaluate the effect of distal ureter management on oncological outcomes in patients with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. 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). 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). 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.