title: Comparative outcomes following endoscopic ureteral detachment and formal bladder cuff excision in open nephroureterectomy for upper urinary tract transitional cell carcinoma.
abstract: OBJECTIVE
  The introduction of laparoscopic nephroureterectomy highlights the need for the critical appraisal of approaches to the distal ureter at surgery for upper tract transitional cell carcinoma. We compared differences after endoscopic ureteral detachment and open bladder cuff excision in nephroureterectomy.
  
  
  METHODS
  A total of 138 patients underwent open nephroureterectomy for upper urinary tract transitional cell carcinoma from 1982 to 2005 with a median followup of 43 months. Of these patients 90 underwent endoscopic ureteral detachment and 48 underwent bladder cuff excision. Demographic, perioperative and oncological outcome data were collected in all cases. Statistical analyses were performed using the Student t test, chi-square and log rank tests, and logistic and Cox regression.
  
  
  RESULTS
  Mean operative duration was significantly lower in the endoscopic detachment group than in the bladder cuff group (p <0.01). There were 49 (54.4%) bladder recurrences in the endoscopic detachment group, of which 8 (16.3%) were muscle invasive and 3 (3.3%) developed at the resection site. There were 23 (47.9%) bladder recurrences in the bladder cuff group, of which 3 (13.0%) were muscle invasive and 2 (4.2%) developed at the resection site. All 5 resection site tumors occurred after excision of muscle invasive distal ureteral tumors and 4 of these had positive margins. There were no differences in recurrence-free survival or disease specific survival between the groups. Operation subtype did not predict oncological outcome on univariate or multivariate analysis.
  
  
  CONCLUSIONS
  Endoscopic ureteral detachment reduces operative duration and is associated with equivalent oncological outcomes compared with open bladder cuff excision in nephroureterectomy. Caution should be exercised in patients with low ureteral tumors.
authors.affiliation: Department of Urology, Nottingham City Hospital, United Kingdom. tjwalton1974@btinternet.com
authors.forename: T J
authors.initials: TJ
authors.lastname: Walton
authors.forename: B T
authors.initials: BT
authors.lastname: Sherwood
authors.forename: R J
authors.initials: RJ
authors.lastname: Parkinson
authors.forename: O
authors.initials: O
authors.lastname: Obakponovwe
authors.forename: S A
authors.initials: SA
authors.lastname: Thomas
authors.forename: M C
authors.initials: MC
authors.lastname: Taylor
authors.forename: R C
authors.initials: RC
authors.lastname: England
authors.forename: R J
authors.initials: RJ
authors.lastname: Lemberger
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007813:Laparotomy / Q000379:methods; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality*; D009392:Nephrectomy / Q000379:methods; D010149:Postoperative Pain / Q000503:physiopathology; D011183:Postoperative Complications; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery; D018666:Ureteroscopy / Q000379:methods; D001743:Urinary Bladder / Q000601:surgery; D014571:Urologic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*