BACKGROUND: The optimal management of the distal ureter and bladder cuff during radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC) is uncertain. Endoscopic techniques are less invasive but may compromise oncological control. OBJECTIVE: To compare oncological outcomes of formal transvesical/extravesical (Tr/Ex) bladder cuff excision versus endoscopic distal ureter management in patients undergoing RNU for UTUC. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective analysis of patients included in the Clinical Research Office of the Endourological Society (CROES) UTUC registry, which prospectively collects data from participating centers worldwide. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was recurrence-free survival (RFS); secondary endpoints were intravesical recurrence (IVR) and overall survival (OS). RFS and OS were assessed using Kaplan-Meier methods and Cox regression, whereas IVR was analyzed using competing-risk methods, including Gray's test and Fine-Gray regression. Multivariable adjustment was applied for the primary endpoint RFS. In the matched cohort, an exploratory interaction analysis was performed by adding a treatment-by-primary-tumor-location interaction term to the multivariable Cox model. RESULTS AND LIMITATIONS: Of 1255 patients, 1109 underwent Tr/Ex resection and 146 received endoscopic management. Propensity score matching yielded 258 matched patients (129/group) with good balance in measured baseline covariates, representing a restricted overlap subset. In the matched cohort, Kaplan-Meier analysis showed better RFS with Tr/Ex than with endoscopic management (log-rank p = 0.034). Univariable Cox analysis yielded a hazard ratio (HR) for recurrence of 0.47 (95% confidence interval CI, 0.23-0.96; p = 0.039), whereas the adjusted Cox model showed a similar but nonsignificant association (HR, 0.49; 95% CI, 0.22-1.10; p = 0.085). OS was similar between groups (HR, 0.96; 95% CI, 0.32-2.89; p > 0.9). In competing-risk analyses treating death without prior IVR as a competing event, the cumulative incidence of IVR did not differ significantly between groups (Gray's test p = 0.064). Fine-Gray regression likewise showed a nonsignificant association between treatment group and IVR (Tr/Ex vs endoscopic: subdistribution hazard ratio sHR, 0.48, 95% CI, 0.22-1.05; p = 0.067). In an exploratory interaction analysis, the estimated HR for Tr/Ex versus endoscopic management was 0.64 (95% CI, 0.23-1.75; p = 0.382) in renal pelvic tumors and 0.39 (95% CI, 0.09-1.71; p = 0.212) in ureteral tumors; however, no statistically significant treatment-by-location interaction was observed (HR for interaction, 0.61; 95% CI, 0.10-3.68; p = 0.590). CONCLUSION: In the matched cohort, Tr/Ex management was associated with longer RFS on Kaplan-Meier analysis, but the adjusted HR favored Tr/Ex without reaching statistical significance. For intravesical recurrence, competing-risk analyses showed no statistically significant difference between groups. No significant interaction by primary tumor location was observed. REGISTRATION: NCT02281188.
Zhao et al. (Fri,) studied this question.