European Urology

For upper urinary tract urothelial carcinoma (UTUC), radical nephroureterectomy with adequate bladder cuff excision is the gold standard in current treatment. There are many procedures for bladder cuff management to ensure en bloc upper urinary tract resection and prevent intraluminal tumor spreading. Xylinas et al. stated that endoscopic bladder cuff excision causes more bladder recurrence than transvesical or extravesical methods [1]; Li et al. presented the similar oncologic control in an endoscopic surgery group [2]. However, the detailed ureter tumor location was not mentioned in either of these studies. In our experience, tumor location might be a potential bias causing such a different oncologic outcome.

In our institution, the bladder cuff excision during radical nephroureterectomy is mainly performed by extravesical and endoscopic methods. Most extravesical bladder cuff excisions use hand-assisted retroperitoneoscopic nephroureterectomy (HARNU), and a better perioperative outcome with less urinary bladder tumor recurrence has been reported [3] and [4]. We further include patients who underwent traditional open nephroureterectomy for analysis. From January 2005 to December 2008, 339 patients with primary UTUC underwent nephroureterectomy at our institution. A total of 238 patients with detailed data were included in our analysis. The median duration of follow-up was 26.88 mo. Most patients were diagnosed with a renal pelvis tumor (71.43%). Tumors were located in the upper, middle, and lower ureter in 18.49%, 13.87%, and 19.75% of the patients, respectively. Sex, age, pathology features, and staging were equally distributed. A total of 128 patients underwent extravesical bladder cuff excision, and 110 patients underwent endoscopic bladder cuff excision. In the extravesical surgery group, surgeons controlled the low ureter first before nephroureterectomy using HARNU or traditional open procedures in our usual practice. In the endoscopic surgery group, the ureteral orifice was electrocauterized and the ureter was ligated early and as low as possible before nephrectomy. Finally, the low ureter with bladder cuff was stripped manually to complete the whole procedure.

In our study, the rates of bladder tumor recurrence, local recurrence, and distant metastasis were 26.88%, 5.04%, and 12.61%, respectively. No significant differences were observed in oncologic outcome between the two groups. However, compared with the extravesical surgery group, the endoscopic surgery group showed a higher rate of bladder tumor recurrence if the tumor was located in the lower third of the ureter (20.83% vs 83.3%, respectively; p = 0.003). For tumors located above the middle ureter, no difference was noted in bladder tumor recurrence. We believe that endoscopic bladder excision combined with the prevention of tumor spread by electrocauterization of the ureter orifice or ligation of the ureter as low as possible can achieve similar oncologic control in patients with upper urinary tract cancer above the middle ureter.

Due to this result, we often shift endoscopic excision to extravesical bladder cuff excision for patients with low ureter cancer. Therefore, it is difficult to conduct a prospective study in our institution. Further analysis by dividing patients according to detailed tumor location would be valuable via a large cohort study with multicenter experiences.

Conflict of interest

The authors have nothing to disclose.