The Management of Distal Ureter During Radical Nephroureterectomy Does Not Influence Bladder Recurrence.

ABSTRACT

Purpose: The bladder cuff (BC) management and its surgical approach represent an essential and debated step in radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. The objective of our study was to determine which BC management has the best oncologic outcomes in terms of bladder recurrence-free survival (BRFS). Methods: We retrospectively analyzed all patients who underwent an open robot-assisted laparoscopic (RNU) or a combined RNU between March 2012 and March 2019 in three academic hospitals. BC management approaches were divided into two categories (O-cuff) open BC and (R-cuff) robot-assisted BC. We assessed demographic characteristics, distal ureter approach, pathology, and operative details, as well as oncologic outcomes including BRFS. Survival was analyzed using the Kaplan-Meier method and compared using the log-rank test. A multivariable analysis was performed to identify predictive factors of bladder recurrence (BR). Results: A total of 117 patients were included with a mean follow-up of 40.4 months. Patients with a history of bladder cancer, RNU with pure laparoscopic approach, and endoscopic BC were excluded. There were 53 (45%) patients in the O-cuff group and 64 (55%) in the R-cuff group. BRFS at 2 years was 73.3% and 72.7% for O-cuff and R-cuff, respectively (p = 0.9). On multivariable analysis, distal ureter tumor (odds ratio 6.24, 95% confidence interval 1.95-21.5; p < 0.01) was associated with BR. Conclusion: There was no statistically significant difference in BRFS between the O-cuff and R-cuff groups. Nevertheless, we underlined that distal ureter tumor was associated with BR. Although we did not find differences regarding the surgical approach, BC remains a very important step of RNU and caution should be taken when performed laparoscopically to avoid any tumor spillage. Risk factors for bladder cancer recurrence might be taken into account for the choice of its surgical approach.