Editing AUA: Upper Tract Urothelial Carcinoma (2023) (section)

===== Radical nephroureterectomy =====

*'''Principles'''
*#'''Complete excision of ipsilateral upper tract urothelium''', including the intramural portion of the ureter and ureteral orifice with negative margins
*##Specimen should be removed en bloc whenever technically feasible
*#'''Avoidance of urinary spillage,''' such as by early low ligation of the ureter, to minimize the risk of seeding urothelial cancer outside the urinary tract.
*'''Approach'''
**Open, robotic, and laparoscopic approaches are suitable
***Minimally invasive approaches were associated with favorable perioperative outcomes including shorter length of stay and fewer complications, and, therefore, are favored for most patients when principles of RNU can be maintained
***Consider open surgical approaches for large, bulky UTUC with clinical evidence for direct invasion to adjacent structures
*'''Bladder cuff excision'''
**Worse local and metastatic recurrence rates with associated decreased CSS and OS for patients who did not receive complete BCE.
**Approach
***Extravesical or transvesical l (e.g., midline cystotomy)
***Open, minimally invasive or transurethral endoscopic techniques. 
****Transurethral endoscopic approaches are associated with higher recurrence rates in the bladder and may limit the ability to utilize post-NU intravesical therapies if the bladder is not fully closed
*'''Complication rates following RNU'''
**Range from 15% to 50% 
**'''30-day mortality risk of 1%'''