Cancer Res Treat.  2021 Jul;53(3):795-802. 10.4143/crt.2020.919.

Effects of Complete Bladder Cuff Removal on Oncological Outcomes Following Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

• Ryoo H
• Kim J
• Kim T
• Kang M
• Jeon HG
• Jeong BC
• Seo SI
• Jeon SS
• Lee HM
• Sung HH

• KMID: 2518403
• DOI: http://doi.org/10.4143/crt.2020.919

Abstract

Purpose
This study aimed to evaluate the effects of bladder cuff method on oncological outcomes in patients who underwent radical nephroureterectomy (RNU) for upper tract urothelial carcinoma.
Materials and Methods
The records of 1,095 patients treated with RNU performed at our hospital between 1994 and 2018 were retrospectively reviewed; 856 patients with no bladder tumor history were enrolled in the present study. The management of bladder cuff was divided into two categories: extravesical ligation (EL) or transvesical resection (TR). Survival was analyzed using the Kaplan-Meier method and Cox regression analyses were performed to determine which factors were associated with intravesical recurrence (IVR)–free survival (IVRFS), cancer-specific survival (CSS), and overall survival (OS).
Results
The mean patient age was 64.8 years and the median follow-up was 37.7 months. Among the 865 patients, 477 (55.7%) underwent the TR and 379 (44.3%) the EL. Significantly higher IVRFS (p=0.001) and OS (p=0.013) were observed in the TR group. In multivariable analysis, IVR, CSS, and OS were independently associated with the EL. Among 379 patients treated with the EL, eight underwent remnant ureterectomy. Based on radical cystectomy–free survival, significant difference was not observed between the two groups. However, significantly higher IVRFS was observed in the TR group when the tumor was located in the renal pelvis.
Conclusion
Intramural complete excision of the distal ureter during RNU should be the gold standard approach compared with EL for the management of distal ureter in terms of oncological outcomes.

Keyword

Upper tract urothelial carcinoma; Bladder cuff method; Oncological outcome

Figure

• 

  Fig. 1 Oncologic outcomes after radical nephroureterectomy according to bladder cuff method: intravesical recurrence-free survival (A), cancer-specific survival (B), and overall survival (C). EL, extravesical ligation; SE, standard error; TR, transvesical resection.

• 

  Fig. 2 Radical cystectomy–free survival after radical nephroureterectomy according to bladder cuff method. EL, extravesical ligation; SE, standard error; TR, transvesical resection.

Reference

References

1. Krabbe LM, Westerman ME, Bagrodia A, Gayed BA, Khalil D, Kapur P, et al. 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. Urol Oncol. 2014; 32:54.

2. Gupta R, Paner GP, Amin MB. Neoplasms of the upper urinary tract: a review with focus on urothelial carcinoma of the pelvicalyceal system and aspects related to its diagnosis and reporting. Adv Anat Pathol. 2008; 15:127–39.

3. Munoz JJ, Ellison LM. Upper tract urothelial neoplasms: incidence and survival during the last 2 decades. J Urol. 2000; 164:1523–5.

4. Allard CB, Alamri A, Dason S, Farrokhyar F, Matsumoto ED, Kapoor A. The method of bladder cuff excision during laparoscopic radical nephroureterectomy does not affect oncologic outcomes in upper tract urothelial carcinoma. World J Urol. 2013; 31:175–81.

5. Lee SM, McKay A, Grimes N, Umez-Eronini N, Aboumarzouk OM. Distal ureter management during nephroureterectomy: evidence from a systematic review and cumulative analysis. J Endourol. 2019; 33:263–73.

6. Azemar MD, Comperat E, Richard F, Cussenot O, Roupret M. Bladder recurrence after surgery for upper urinary tract urothelial cell carcinoma: frequency, risk factors, and surveillance. Urol Oncol. 2011; 29:130–6.

7. Xylinas E, Rink M, Cha EK, Clozel T, Lee RK, Fajkovic H, et al. Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma. Eur Urol. 2014; 65:210–7.

8. Roupret M, Zigeuner R, Palou J, Boehle A, Kaasinen E, Sylvester R, et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol. 2011; 59:584–94.

9. Roupret M, Babjuk M, Comperat E, Zigeuner R, Sylvester R, Burger M, et al. European guidelines on upper tract urothelial carcinomas: 2013 update. Eur Urol. 2013; 63:1059–71.

10. Phe V, Cussenot O, Bitker MO, Roupret M. Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy? BJU Int. 2011; 108:130–8.

11. Roupret M, Babjuk M, Comperat E, Zigeuner R, Sylvester RJ, Burger M, et al. European Association of Urology guidelines on upper urinary tract urothelial carcinoma: 2017 update. Eur Urol. 2018; 73:111–22.

12. Li WM, Shen JT, Li CC, Ke HL, Wei YC, Wu WJ, et al. Oncologic outcomes following three different approaches to the distal ureter and bladder cuff in nephroureterectomy for primary upper urinary tract urothelial carcinoma. Eur Urol. 2010; 57:963–9.

13. Lughezzani G, Sun M, Perrotte P, Shariat SF, Jeldres C, Budaus L, et al. Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study. Eur Urol. 2010; 57:956–62.

14. Walton TJ, Sherwood BT, Parkinson RJ, Obakponovwe O, Thomas SA, Taylor MC, et al. Comparative outcomes following endoscopic ureteral detachment and formal bladder cuff excision in open nephroureterectomy for upper urinary tract transitional cell carcinoma. J Urol. 2009; 181:532–9.

15. Romero FR, Schaeffer EM, Muntener M, Trock B, Kavoussi LR, Jarrett TW. Oncologic outcomes of extravesical stapling of distal ureter in laparoscopic nephroureterectomy. J Endourol. 2007; 21:1025–7.

16. Ko R, Chew BH, Hickling DR, Razvi H, Luke PP, Chin JL, et al. Transitional-cell carcinoma recurrence rate after nephroureterectomy in patients who undergo open excision of bladder cuff v transurethral incision of the ureteral orifice. J Endourol. 2007; 21:730–4.

17. Matin SF, Gill IS. Recurrence and survival following laparoscopic radical nephroureterectomy with various forms of bladder cuff control. J Urol. 2005; 173:395–400.

18. Saika T, Nishiguchi J, Tsushima T, Nasu Y, Nagai A, Miyaji Y, et al. Comparative study of ureteral stripping versus open ureterectomy for nephroureterectomy in patients with transitional carcinoma of the renal pelvis. Urology. 2004; 63:848–52.

19. Salvador-Bayarri J, Rodriguez-Villamil L, Imperatore V, Palou Redorta J, Villavicencio-Mavrich H, Vicente-Rodriguez J. Bladder neoplasms after nephroureterectomy: does the surgery of the lower ureter, transurethral resection or open surgery, influence the evolution? Eur Urol. 2002; 41:30–3.

20. Lai S, Guo R, Seery S, Wu P, Liu J, Zhang Y, et al. Assessing the impact of different distal ureter management techniques during radical nephroureterectomy for primary upper urinary tract urothelial carcinoma on oncological outcomes: a systematic review and meta-analysis. Int J Surg. 2020; 75:165–73.

21. Kapoor A, Dason S, Allard CB, Shayegan B, Lacombe L, Rendon R, et al. The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence. Can Urol Assoc J. 2014; 8:E845–52.

22. McCarron JP, Mills C, Vaughn ED Jr. Tumors of the renal pelvis and ureter: current concepts and management. Semin Urol. 1983; 1:75–81.

23. Kakizoe T, Fujita J, Murase T, Matsumoto K, Kishi K. Transitional cell carcinoma of the bladder in patients with renal pelvic and ureteral cancer. J Urol. 1980; 124:17–9.

24. Babaian RJ, Johnson DE. Primary carcinoma of the ureter. J Urol. 1980; 123:357–9.

25. Bloom NA, Vidone RA, Lytton B. Primary carcinoma of the ureter: a report of 102 new cases. J Urol. 1970; 103:590–8.

26. Strong DW, Pearse HD. Recurrent urothelial tumors following surgery for transitional cell carcinoma of the upper urinary tract. Cancer. 1976; 38:2173–83.

27. Strong DW, Pearse HD, Tank ES Jr, Hodges CV. The ureteral stump after nephroureterectomy. J Urol. 1976; 115:654–5.

28. Sung HH, Jeon HG, Han DH, Jeong BC, Seo SI, Lee HM, et al. Diagnostic ureterorenoscopy is associated with increased intravesical recurrence following radical nephroureterectomy in upper tract urothelial carcinoma. PLoS One. 2015; 10:e0139976.

29. Margulis V, Shariat SF, Matin SF, Kamat AM, Zigeuner R, Kikuchi E, et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009; 115:1224–33.

30. Nazzani S, Preisser F, Mazzone E, Tian Z, Mistretta FA, Soulieres D, et al. Nephroureterectomy with or without bladder cuff excision for localized urothelial carcinoma of the renal pelvis. Eur Urol Focus. 2020; 6:298–304.