Transurethral approach to the distal ureter in nephroureterectomy: transurethral extraction vs. "pluck" technique with long-term follow-up.

Abstract

We retrospectively compared two techniques of transurethral management of the lower ureter in nephroureterectomy. From August 1992 to December 2003, 34 patients underwent either transurethral detachment of the intramural ureter and cephalad extraction ("pluck"; Group 1, N = 18) or transection of the ureter with subsequent transurethral extraction (Group 2, N = 16). Choice of technique was left to the operating surgeon. All patients with upper tract urothelial carcinoma (TCC) were regularly followed by cystoscopy and abdominal ultrasound. Of the 34 patients, 29 had upper tract TCC. Mean follow-up in these was 44 months (range: 1-129), with 24 (83.8%) over 24 months. On follow-up, 14 bladder tumors (all superficial) occurred in 7 patients (24.1%), but in no case on the scar of the excised ureteral orifice. No extravesical recurrences in the former ureteral bed were found. Of the 29 with upper tract TCC, 19 (65.5%) are alive without disease (median 45 months, range: 6-129), 5 (17.2%) have died with no evidence of disease (median 34 months, range: 20-58), and 4 (13.8%) have died from progressive disease (median 18 months, range: 1-33); 1 patient was lost to follow-up at 34 months with no evidence of disease. Differences between techniques with regard to blood loss, operative time, complications, and oncologic outcome were not significant. Both techniques proved technically and oncologically safe. Bladder tumor recurrence rate was in the range reported for classic nephroureterectomy. No extravesical tumor recurrence in the former ureteral bed or on the scar of the resected ureteral orifice occurred.