To compare the outcome of distal ureterectomy and nephroureterectomy for high-risk urothelial carcinoma (UTUC) at distal ureter.

This is a retrospective review of patients with curative surgery, nephroureterectomy or distal ureterectomy, performed for high-risk UTUC at distal ureter in a tertiary hospital in Hong Kong. The electronic health records of the patients were reviewed to retrieve clinical data including patients’ demographics, pre-operative radiological and histological findings, details of the surgery performed, post-operative pathology results, recovery and oncological outcome. Patients with concomitant tumour at renal pelvis, upper or mid ureter, a history of radical cystectomy or non-urothelial carcinoma pathology were excluded. For statistical method, t-test and chi-square test were performed for comparison between the two groups. Kaplan-Meier and cox regression analysis were performed to review oncological outcome.

From January 2010 to June 2023, a total of 44 patients with UTUC at distal ureter had surgery in Tuen Mun Hospital, with 22 distal ureterectomy. All distal ureterectomy were performed in open approach. The nephroureterectomy were performed in open or laparoscopic approach. Pluck technique or open cystostomy was used in managing bladder cuff. The patients’ mean age was 68.3±8.2 years. Most tumours were high grade or grade 3 (63.6%). Hydronephrosis was present in 80% of them. Between the two groups, there was no difference in age (p=0.464), renal function (p=0.635), classification on American Society of Anesthesiologists (p=0.186), tumour grade (p=0.988) or tumour stage (p=0.136), presence of hydronephrosis (p=0.067), suspicious or malignant urine cytology (p=0.352), carcinoma-in-situ (p=0.916), or variant histology (p=0.863). The distal ureterectomy group had more patients with previous bladder cancer (4.5% vs 31.8%, p=0.019) and smaller tumour size (19.5±9.5 vs 25.8±13.2mm, p=0.041). Intra-operatively, the distal ureterectomy group had a shorter operative duration (241.1±43.1 vs 310.5±76.5 minutes, p<0.001) and less intra-operative blood loss (545.2±430.0 vs 803.1±557.6ml, p=0.05). During the post-operative course, there was no significant difference in terms of length of stay (p=0.236), presence of complications (p=0.741) and unplanned admission in 30 days (p=0.434). However, the change in serum creatinine level at about 6 months after surgery is less in the distal ureterectomy group (3.1±14.8 vs 16.8±28.9, p=0.03). There was no significant difference in oncological outcome in terms of overall survival, cancer-specific survival, metastasis, bladder or local recurrence.

Distal ureterectomy is potentially a treatment for UTUC at distal ureter with an advantage of a shorter operative duration and less intra-operative blood loss, while the disease control is not compromised.