Introduction: Radical nephroureterectomy (RNU) is widely considered the gold standard in high-risk upper tract urothelial carcinoma (UTUC). Segmental ureterectomy (SU) has had increased adoption for high-risk UTUC, particularly for distal ureteric tumors, but its oncological equivalence remains unclear. We sought to examine current trends in RNU and SU for UTUC, patient factors contributing to the performance of SU, compare the rates of lymph node dissection (LND), and examine survival for RNU and SU in high-risk disease.

Methods: A large national hospital-based database (The National Cancer Database) was used to identify all patients from 2004 to 2016 with nonmetastatic UTUC with urothelial histology who underwent extirpative surgery (either RNU or SU). Patient factors and rates of LND were compared, with subgroup analysis performed based on high-risk features (high grade tumor, tumor over 2cm, pT2-4 disease). Kaplan-Meier methods and log-rank testing were used for survival analysis overall and across high-risk subgroups. 

Results: 30861 patients with UTUC were identified from 2004 to 2016 who underwent extirpative surgery. 26153 (84.7%) of these patients underwent RNU, and 4708 (15.3%) underwent SU.  SU patients were older, more likely to have surgery at an Academic/Research hospital, have lower cT, cN, pT, and pN stages, have pM0 disease, have low grade tumor, be done through open surgery, and have a higher rate of positive margins (p<0.001 for all) (Table 1).

LND was more likely to be performed with SU (32.2%) vs. RNU (23.0%) (p<0.001). This was consistent across high grade tumors, tumors over 2cm, and pT2-3 disease (Table 2). When patients had a LND, SU had higher nodal yields, with a mean of 6.07 nodes and median of 4 nodes, vs RNU, with a mean of 5.69 nodes and median of 3 nodes.

SU was associated with improved OS (p=0.025) with a median survival of 66.1 months for SU and 64.9 months for RNU (Figure 1).  This was not consistent across high-risk subgroups; there was no significant difference in survival for high grade tumors (p=0.14), tumors over 2cm (p=0.37), pT2 disease (p=0.072), and pT4 disease (p=0.27), with RNU having better survival for pT3 disease (p<0.001) (Figure 2).

Conclusions: Patients undergoing SU were more likely to be older, have surgery at an Academic/Research hospital, have lower stage disease, have low grade tumor, have open surgery, and had a higher rate of positive margins. LND was more likely to be performed with SU vs. RNU, and this was consistent across high-risk subgroups. When patients underwent LND, SU yielded more nodes on average. SU was associated with improved OS compared to RNU for the entire cohort, but there was no statistical difference in survival across high-risk subgroups outside of pT3 disease.

While further prospective studies need to be done, SU appears to be non-inferior to RNU in selected high-risk patients.