title: The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence.
abstract: BACKGROUND
  Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) must include some form of distal ureter management to avoid high rates of tumour recurrence. It is uncertain which distal ureter management technique has the best oncologic outcomes. To determine which distal ureter management technique resulted in the lowest tumour recurrence rate, we analyzed a multi-institutional Canadian radical nephroureterectomy database.
  
  
  METHODS
  We retrospectively analyzed patients who underwent radical nephroureterectomy with distal ureter management for UTUC between January 1990 and June 2010 at 10 Canadian tertiary hospitals. Distal ureter management approaches were divided into 3 categories: (1) extravesical tenting for ureteric excision without cystotomy (EXTRAVESICAL); (2) open cystotomy with intravesical bladder cuff excision (INTRAVESICAL); and (3) extravesical excision with endoscopic management of ureteric orifice (ENDOSCOPIC). Data available for each patient included demographic details, distal ureter management approach, pathology and operative details, as well as the presence and location of local or distant recurrence. Clinical outcomes included overall recurrence-free survival and intravesical recurrence-free survival. Survival analysis was performed with the Kaplan-Meier method. Multivariable Cox regression analysis was also performed.
  
  
  RESULTS
  A total of 820 patients underwent radical nephroureterectomy with a specified distal ureter management approach at 10 Canadian academic institutions. The mean patient age was 69.6 years and the median follow-up was 24.6 months. Of the 820 patients, 406 (49.5%) underwent INTRAVESICAL, 316 (38.5%) underwent EXTRAVESICAL, and 98 (11.9%) underwent ENDOSOPIC distal ureter management. Groups differed significantly in their proportion of females, proportion of laparoscopic cases, presence of carcinoma in situ and pathological tumour stage (p < 0.05). Recurrence-free survival at 5 years was 46.3%, 35.6%, and 30.1% for INTRAVESICAL, EXTRAVESICAL and ENDOSCOPIC, respectively (p < 0.05). Multivariable Cox regression analysis confirmed that INTRAVESICAL resulted in a lower hazard of recurrence compared to EXTRAVESICAL and ENDOSCOPIC. When looking only at intravesical recurrence-free survival (iRFS), a similar trend held up with INTRAVESICAL having the highest iRFS, followed by ENDOSCOPIC and then EXTRAVESICAL management (p < 0.05). At last follow-up, 406 (49.5%) patients were alive and free of disease.
  
  
  CONCLUSIONS
  Open intravesical excision of the distal ureter (INTRAVESICAL) during radical nephroureterectomy was associated with improved overall and intravesical recurrence-free survival compared with extravesical and endoscopic approaches. These findings suggest that INTRAVESICAL should be considered the gold standard oncologic approach to distal ureter management during radical nephroureterectomy. Limitations of this study include its retrospective design, heterogeneous cohort, and limited follow-up.
authors.affiliation: McMaster Universty, Hamilton, ON;
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authors.initials: A
authors.lastname: Kapoor
authors.affiliation: McMaster Universty, Hamilton, ON;
authors.forename: Shawn
authors.initials: S
authors.lastname: Dason
authors.affiliation: McMaster Universty, Hamilton, ON;
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Allard
authors.affiliation: McMaster Universty, Hamilton, ON;
authors.forename: Bobby
authors.initials: B
authors.lastname: Shayegan
authors.affiliation: Laval University, Quebec, QC;
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authors.initials: L
authors.lastname: Lacombe
authors.affiliation: Dalhousie University, Halifax, NS;
authors.forename: Ricardo
authors.initials: R
authors.lastname: Rendon
authors.affiliation: University of Alberta, Edmonton, AB;
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authors.initials: NE
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authors.affiliation: University of Alberta, Edmonton, AB;
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authors.lastname: Fairey
authors.affiliation: University of Western Ontario, London, ON;
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authors.lastname: Izawa
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authors.affiliation: McGill University, Montreal, QC;
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authors.lastname: Tanguay
authors.affiliation: University of Western Ontario, London, ON;
authors.forename: Joseph
authors.initials: J
authors.lastname: Chin
authors.affiliation: University of British Columbia, Vancouver, BC;
authors.forename: Alan
authors.initials: A
authors.lastname: So
authors.affiliation: University of Montreal, Montreal, QC;
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Lattouf
authors.affiliation: Dalhousie University, Halifax, NS;
authors.forename: David
authors.initials: D
authors.lastname: Bell
authors.affiliation: University of Montreal, Montreal, QC;
authors.forename: Fred
authors.initials: F
authors.lastname: Saad
authors.affiliation: University of Manitoba, Winnipeg, MB;
authors.forename: Darrell
authors.initials: D
authors.lastname: Drachenberg
authors.affiliation: University of Ottawa, Ottawa, ON;
authors.forename: Ilias
authors.initials: I
authors.lastname: Cagiannos
authors.affiliation: Laval University, Quebec, QC;
authors.forename: Yves
authors.initials: Y
authors.lastname: Fradet
authors.affiliation: King Khalid University, Abha, Saudi Arabia.
authors.forename: Abdulaziz
authors.initials: A
authors.lastname: Alamri
authors.affiliation: McGill University, Montreal, QC;
authors.forename: Wassim
authors.initials: W
authors.lastname: Kassouf