Abstract

Background and objective
Distal ureterectomy (DU) is a kidney-sparing option for low-risk upper tract urothelial carcinoma (UTUC) and may be considered for selected high-risk cases. Long-term outcomes and recurrence predictors remain poorly defined. Our aim was to evaluate oncological outcomes of DU and identify preoperative predictors of disease recurrence, with a particular focus on ipsilateral upper tract recurrence (iUTR).
Methods
This retrospective multicentre study included 450 patients with nonmetastatic UTUC in the distal ureter treated with DU and bladder cuff excision between 2010 and 2023. The primary endpoint was iUTR-free survival (iUTRFS). Secondary endpoints were intravesical recurrence-free survival (IVRFS), recurrence-free survival (RFS), cancer-specific survival (CSS), overall survival (OS), and perioperative outcomes. Survival outcomes were visualised using Kaplan-Meier curves, and multivariable Cox regression analyses were performed.
Key findings and limitations
The 5-yr survival estimates were 82% for iUTRFS, 49% for IVRFS, 81% for RFS, 89% for CSS, and 72% for OS. IVRFS, iUTRFS, CSS, and OS did not significantly differ between the low-risk and high-risk groups. iUTR occurred in 16% of patients, with one in four of these cases arising after 5 yr. Salvage radical nephroureterectomy was performed in 10% of patients. Preoperative double-J stenting (hazard ratio [HR] 2.85, 95% confidence interval [CI] 1.11–7.30), tumour size (HR 1.04, 95% CI 1.01–1.07) and endoscopic bladder cuff management (HR 9.73, 95% CI 1.66–56.89) were independent predictors of iUTR. Perioperative complications were rare, with only 7% graded as high grade within 90 d. Limitations include the retrospective design, lack of centralised pathology review, and variability in surgical technique.
Conclusions and clinical implications
DU provides favourable perioperative and long-term oncological outcomes and may also be appropriate for selected high-risk cases. iUTR is not uncommon, and prolonged upper tract follow-up is essential. Avoidance of preoperative stenting and endoscopic bladder cuff management may reduce the risk of iUTR.