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

===== Ureterectomy =====

*'''Options'''
**'''<span style="color:#ff0000">Segmental ureterectomy with ureteroureterostomy</span>''' 
***'''<span style="color:#ff0000">Small, unifocal tumors (typically 1 cm or smaller) tumors isolated to a short segment of the proximal or mid-ureter requiring resection of ≤2 cm or less of ureteral length to allow for primary ureteroureterostomy.</span>''' 
****Longer sections of ureteral involvement and resection may require more complex reconstruction techniques when kidney sparing is desired.
**'''<span style="color:#ff0000">Distal ureterectomy with ureteral reimplant</span>'''
***'''<span style="color:#ff0000">Preferred treatment for surgically eligible patients with HR and unfavorable LR cancers endoscopically confirmed as confined to the lower ureter in a functional renal unit</span>'''
****Tumor ablation considered alternative options to the gold-standard of extirpative resection
*****Tumor ablation may yield less optimal results and require multiple additional procedures
***Most favorable candidates for distal ureterectomy are patients who
****Have ureteral tumors in the lower third of the ureter
****Sufficiently mobile bladder with capacity to facilitate reimplantation with or without reconfiguration of the bladder to facilitate a tension-free anastomosis (i.e., Boari flap or psoas hitch maneuver).
*'''Reasonable alternatives to RNU for well-selected patients'''
*Principles
*#'''Patient counseling''' to describe techniques, potential requirements for urinary reconstruction and associated complications including the potential impact on postoperative bladder function.
*#'''Preoperative endoscopic assessment''' to evaluate sites of involvement and proximal extent of disease.
*#'''Preoperative assessment of bladder capacity''' and function in cases where more extensive reconstruction such as a Boari flap are anticipated to permit a tension free ureterovesical anastomosis or the use of bowel segments.
*#'''Intraoperative pathologic assessment''' (i.e., frozen sections) of proximal and distal margins to ensure complete resection with negative margins.
*#Reasonable attempts to '''avoid of spillage of urine''' into the surgical field.
*#'''Watertight, tension free closure''' to facilitate functional healing and avoid urine leak (of urine potentially contaminated with malignant cells).

*'''When performing NU or distal ureterectomy, the entire distal ureter including the intramural ureteral tunnel and ureteral orifice should be excised, and the urinary tract should be closed in a watertight fashion.'''
**The resultant hiatus in the bladder in the location of the excised ureteral orifice with or without the bladder cuff can be closed formally in a watertight fashion in one or more layers
***A formal BCE with watertight closure of the bladder cuff should be performed to
***#Avoid urinary extravasation from the bladder
***#Facilitate more rapid catheter removal
***#Permit instillation of intravesical adjuvant chemotherapy in the perioperative setting
***Delayed closure by secondary intension in a decompressed bladder without formal bladder closure has also been described.