Oncologic outcomes following nephroureterectomy for upper tract urothelial carcinoma are not compromised when the surgeon removes the bladder cuff via a transurethral incision.

Excision of the bladder cuff is an integral component of the gold standard treatment for upper tract urothelial carcinoma—radical nephroureterectomy. There is, however, no consensus as to the optimal approach to removal of the bladder cuff. After analyzing data from a large patient cohort, researchers in Taiwan now conclude that the method by which the bladder cuff is removed has no effect on cancer-specific outcomes.

The number of techniques by which the bladder cuff can be excised has increased since the advent of laparoscopic nephroureterectomy. Li et al.'s retrospective analysis includes data from just over 300 patients, in whom an intravesical, extravesical or transurethral incision was made to access the bladder cuff during either open or laparoscopic nephroureterectomy.

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Selection of technique was at the discretion of the surgeon. About one-fifth of nephroureterectomies that comprise the Taiwanese series were performed laparoscopically. Most surgeons chose the extravesical or transurethral approach to bladder cuff excision during these laparoscopic procedures.

Concern that the transurethral method is associated with an increased risk of tumor recurrence in the bladder was not borne out by the current study; no differences in bladder-recurrence-free survival were found between the three groups. Nor were any differences in local retroperitoneal recurrence, contralateral recurrence, or distant metastasis evident during a mean follow-up period of approximately 3 years.

“Bladder tumor recurrence might arise from microscopic tumor seeding or chronic carcinogen stimulation”, write the authors. They suggest two methods—endoscopic coagulation of the ureteral orifice before resection, and ligation of the ureter below the tumor prior to nephrectomy—to minimize the likelihood of residual tumor cell implantation.

As in previous studies, cancer-specific survival (41 deaths) was found to be significantly influenced by tumor stage and grade only. No correlation with mode of bladder cuff control was detected. The authors assert that their findings support use of transurethral incisions for bladder cuff control during nephroureterectomy for upper tract urothelial carcinoma. Validation in a prospective setting is awaited.