Abstract: PD66-11
Sources of Funding: None

Introduction

Radical nephroureterectomy (RNU) with excision of a bladder cuff remains the standard treatment for upper tract urothelial carcinoma (UTUC). However, the approach to surgical excision of the distal ureter remains understudied with studies reporting conflicting results. Herein, we report oncologic outcomes for two approaches to resection of the distal ureter using a large single-center database.

Methods

We reviewed 372 patients treated with RNU for UTUC who underwent intra- or extravesical bladder cuff excision from 1995 to 2009. Intravesical excision was defined as a separate anterior cystotomy with circumferential excision of the distal ureter, while extravesical excision was a lateral cystotomy encompassing the ipsilateral ureteral orifice. Patients with metastatic disease at RNU, neoadjuvant chemotherapy, and non-urothelial primary were excluded. Multivariable Cox regression analysis was performed to evaluate characteristics associated with patients’ risk of cancer-specific mortality (CSM). Kaplan-Meier analysis was used to evaluate recurrence free survival (RFS).

Results

Median patient age at RNU was 73.7 years (IQR 65.4, 79.5); 67% (n=249) were male and 64% (n=238) underwent extravesical excision. Median follow-up was 47 months (IQR 16.4, 101.4), during which time 52.4% (n=195) experienced a bladder or systemic recurrence and 17.5% (n=65) died due to metastatic urothelial carcinoma. There was no statistically significant difference for 5-year RFS between the two groups (p=0.29). On multivariable analysis features independently associated with increased risk of CSM included smoking history (HR 2.31; p=0.03), high grade (HR 4.23; p<0.001), pT2 or higher (HR 2.51; p=0.01), lymph node positive disease(HR 4.29; p<0.01) and tumor size > 3 cm (HR 2.10; p=0.02). Importantly, approach to the bladder cuff excision was not associated with an increased risk of disease recurrence (HR=1.11; p=0.60) or CSM (HR 1.26; p=0.52).

Conclusions

Excision of the entire ureter, including the intramural component, is an important part of RNU. However, intra- or extravesical approach to the distal ureter, does not affect RFS or CSM. Therefore, our data validates the oncologic safety of both approaches to the bladder cuff for patients undergoing RNU for UTUC.

Funding

None