Is Segmental Ureterectomy Associated with Inferior Survival for Localized Upper-Tract Urothelial Carcinoma of the Ureter Compared to Radical Nephroureterectomy?

SIMPLE SUMMARY: National cancer registry data showed that segmental ureterectomy is not associated with inferior survival compared to radical nephroureterectomy in upper-tract urothelial carcinoma patients. Segmental ureterectomy provides a valid surgical approach that does not meaningfully sacrifice survival outcomes within appropriately selected patients of upper urothelial carcinoma of the ureter. Given the potential renal functional preservation benefits, segmental ureterectomy should be considered for selected patients, especially if there is an increased probability of requiring adjuvant chemotherapy. ABSTRACT: Segmental ureterectomy (SU) is an alternative to radical nephroureterectomy (RNU) in the treatment of upper-tract urothelial carcinoma (UTUC) of the ureter. SU generally preserves renal function, at the expense of less intensive cancer control. We aim to assess whether SU is associated with inferior survival compared to RNU. Using the National Cancer Database (NCDB), we identified patients diagnosed with localized UTUC of the ureter between 2004–2015. We used a propensity-score-overlap-weighted (PSOW) multivariable survival model to compare survival following SU vs. RNU. PSOW-adjusted Kaplan–Meier curves were generated and we performed a non-inferiority test of overall survival. A population of 13,061 individuals with UTUC of the ureter receiving either SU or RNU was identified; of these, 9016 underwent RNU and 4045 SU. Factors associated with decreased likelihood of receiving SU were female gender (OR, 0.81; 95% CI, 0.75–0.88; p < 0.001), advanced clinical T stage (cT4) (OR, 0.51; 95% CI, 0.30–0.88; p = 0.015), and high-grade tumor (OR, 0.76; 95% CI, 0.67–0.86; p < 0.001). Age greater than 79 years was associated with increased probability of undergoing SU (OR, 1.18; 95% CI, 1.00–1.38; p = 0.047). There was no statistically significant difference in OS between SU and RNU (HR, 0.98; 95% CI, 0.93–1.04; p = 0.538). SU was not inferior to RNU in PSOW-adjusted Cox regression analysis (p < 0.001 for non-inferiority). In weighted cohorts of individuals with UTUC of the ureter, the use of SU was not associated with inferior survival compared to RNU. Urologists should continue to utilize SU in appropriately selected patients.