title: 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.
abstract: OBJECTIVE
  To evaluate the effect of distal ureter management on oncological outcomes in patients with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma.
  
  
  METHODS
  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).
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, University of Muenster Medical Center, Muenster, Germany.
authors.forename: Laura-Maria
authors.initials: LM
authors.lastname: Krabbe
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Westerman
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Aditya
authors.initials: A
authors.lastname: Bagrodia
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Bishoy A
authors.initials: BA
authors.lastname: Gayed
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Dina
authors.initials: D
authors.lastname: Khalil
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Payal
authors.initials: P
authors.lastname: Kapur
authors.affiliation: Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Ganesh V
authors.initials: GV
authors.lastname: Raj
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Arthur I
authors.initials: AI
authors.lastname: Sagalowsky
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Cadeddu
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Yair
authors.initials: Y
authors.lastname: Lotan
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address: vitaly.margulis@utsouthwestern.edu.
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods*; D011379:Prognosis; D012189:Retrospective Studies; D012196:Review Literature as Topic; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014571:Urologic Neoplasms / Q000473:pathology / Q000601:surgery*
keywords: Nephroureterectomy; Prognosis; Surgical management; Upper tract; Urothelial carcinoma