Editing Upper Urinary Tract Urothelial Cancer (section)

=====Radical nephroureterectomy with bladder cuff excision=====

====== Principles[https://pubmed.ncbi.nlm.nih.gov/37096584/] ======
#'''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.

====== Outcomes ======
*Largely dependent on clinicopathologic characteristics.
*'''<span style="color:#ff00ff">Systematic review and meta-analysis comparing nephron-sparing approach to radical nephroureterectomy (2016)</span>'''
** Primary outcome: cancer-specific survival
** Results
*** Included 22 studies published between 1999 and 2015
**** No RCTs comparing nephron-sparing approach and nephroureterectomy
*** High risk of bias across all domains analysed, limiting interpretation of comparisons
*** Segemental ureterectomy vs. RNU (10 studies): no significant difference in cancer-specific survival
*** Endoscopic vs. RNU
**** URS vs. RNU (5 studies): no significant difference in cancer-specific survival
***** Grade-based subgroup analyses found decreased cancer-specific survival in patients undergoing URS for high-grade disease
**** Percutaneous resection vs. RNU (2 studies): conflicting findings
** Seisen, Thomas, et al."Oncologic outcomes of kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma: a systematic review by the EAU non-muscle invasive bladder cancer guidelines panel." ''European urology'' 70.6 (2016): 1052-1068.

====== Technique ======
*See Nephroureterectomy Chapter Notes for technical aspects
*'''Approach[https://pubmed.ncbi.nlm.nih.gov/37096584/]'''
**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[https://pubmed.ncbi.nlm.nih.gov/37096584/]'''
**Worse local and metastatic recurrence rates with associated decreased CSS and OS for patients who did not receive complete BCE.
** Approach
***Extravesical or transvesical (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

====== Adverse events ======
*Range from 15% to 50%
* '''30-day mortality risk of 1%'''