Editing Upper Urinary Tract Urothelial Cancer (section)

=====Segmental Ureterectomy=====
*'''Reasonable alternative to RNU for well-selected patients'''

====== 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).

====== 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).

====== Outcomes ======
* '''<span style="color:#ff00ff">Systematic review and meta-analysis comparing segmental resection to radical nephroureterectomy (2020)</span>'''
** Results:
*** Included 18 studies comprising 4797 patients, of which 1313 underwent segmental resection
*** High risk of bias across all domains analysed, limiting interpretation of comparisons
*** 5-yr:
**** Recurrence-free survival: significantly worse with segmental resection
**** Cancer-specific survival: no significant difference
**** OS: no significant difference
*** Veccia, Alessandro, et al."Segmental ureterectomy for upper tract urothelial carcinoma: a systematic review and meta-analysis of comparative studies." ''Clinical genitourinary cancer'' 18.1 (2020): e10-e20.
* Segmental ureterectomy of the proximal two-thirds of ureter is associated with higher failure rates than for the distal ureter.

====== Technique ======
* Risk of wound implantation by tumor is low after open segmental ureterectomy if simple precautions are followed to minimize spillage
*See Segmental Ureterectomy Chapter Notes for technical aspects
*'''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.