title: Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma.
abstract: BACKGROUND
  There is a lack of consensus regarding the optimal approach to the bladder cuff during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).
  
  
  OBJECTIVE
  To compare the oncologic outcomes following RNU using three different methods of bladder cuff management.
  
  
  METHODS
  Retrospective analysis of 2681 patients treated with RNU for UTUC at 24 international institutions from 1987 to 2007.
  
  
  METHODS
  Three methods of bladder cuff excision were performed: transvesical, extravesical, and endoscopic.
  
  
  METHODS
  Univariable and multivariable models tested the effect of distal ureter management on intravesical recurrence, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS).
  
  
  CONCLUSIONS
  Of the 2681 patients, 1811 (67.5%) underwent the transvesical approach; 785 (29.3%), the extravesical approach; and 85 (3.2%), the endoscopic approach. There was no difference in terms of RFS, CSS, and OS among the three distal ureteral management approaches. Patients who underwent the endoscopic approach were at significantly higher risk of intravesical recurrence compared with those who underwent the transvesical (p=0.02) or extravesical approaches (p=0.02); the latter two groups did not differ from each other (p=0.40). Actuarial intravesical RFS estimates at 2 and 5 yr after RNU were 69% and 58%, 69% and 51%, and 61% and 42% for the transvesical, extravesical, and endoscopic approaches, respectively. In multivariate analyses, distal ureteral management (p=0.01), surgical technique (open vs laparoscopic; p=0.02), previous bladder cancer (p<0.001), higher tumor stage (trend; p=0.01), concomitant carcinoma in situ (CIS) (p<0.001), and lymph node involvement (trend; p<0.001) were all associated with intravesical recurrence. Excluding patients with history of previous bladder cancer, all variables remained independent predictors of intravesical recurrence.
  
  
  CONCLUSIONS
  The endoscopic approach was associated with higher intravesical recurrence rates. Interestingly, concomitant CIS in the upper tract is a strong predictor of intravesical recurrence after RNU. The association of laparoscopic RNU with intravesical recurrence needs to be further investigated.
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA; Department of Urology Cochin Hospital, APHP, Paris Descartes University, Paris, France.
authors.forename: Evanguelos
authors.initials: E
authors.lastname: Xylinas
authors.forename: Michael
authors.initials: M
authors.lastname: Rink
authors.forename: Eugene K
authors.initials: EK
authors.lastname: Cha
authors.forename: Thomas
authors.initials: T
authors.lastname: Clozel
authors.forename: Richard K
authors.initials: RK
authors.lastname: Lee
authors.forename: Harun
authors.initials: H
authors.lastname: Fajkovic
authors.forename: Evi
authors.initials: E
authors.lastname: Comploj
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.forename: Jay D
authors.initials: JD
authors.lastname: Raman
authors.forename: Yair
authors.initials: Y
authors.lastname: Lotan
authors.forename: Wassim
authors.initials: W
authors.lastname: Kassouf
authors.forename: Hans-Martin
authors.initials: HM
authors.lastname: Fritsche
authors.forename: Alon
authors.initials: A
authors.lastname: Weizer
authors.forename: Juan I
authors.initials: JI
authors.lastname: Martinez-Salamanca
authors.forename: Kazumasa
authors.initials: K
authors.lastname: Matsumoto
authors.forename: Richard
authors.initials: R
authors.lastname: Zigeuner
authors.forename: Armin
authors.initials: A
authors.lastname: Pycha
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Scherr
authors.forename: Christian
authors.initials: C
authors.lastname: Seitz
authors.forename: Thomas
authors.initials: T
authors.lastname: Walton
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
authors.forename: Surena
authors.initials: S
authors.lastname: Matin
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Marc
authors.initials: M
authors.lastname: Zerbib
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D012189:Retrospective Studies; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000601:surgery*