Impact of bladder cuff management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma: A systematic review and meta-analysis.

Introduction: Bladder cuff excision (BCE) is an integral component of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). While many approaches have been described, the optimal technique for BCE to provide maximal oncologic control remains unanswered. We aimed to perform a systematic review and meta-analysis to compare oncologic outcomes of different BCE techniques.

Methods: The Ovid MEDLINE, Embase, CENTRAL, and Web of Science databases were searched for studies comparing oncologic outcomes of RNU for UTUC based on different BCE approaches. Techniques for BCE were categorized as intravesical, extravesical, or endoscopic. Our primary outcomes were intravesical recurrence rate (IVR) and intravesical recurrence-free survival (IVRFS). Secondary outcomes included recurrence-free survival (RFS) and cancer-specific survival (CSS). Meta-analysis was performed to compare the recurrence rates and survival outcomes associated with different BCE techniques.

Results: Forty studies assessing a total of 17 168 patients were identified for inclusion. Open intravesical BCE was associated with superior univariate IVRFS (hazard ratio [HR] 1.27, 95% confidence interval [CI] 1.13-1.42, p=0.04, I²=43%), multivariate IVRFS (HR 1.44, 95% CI 1.16-1.80, p<0.0001, I²=75%), univariate RFS (HR 2.30, 95% CI 1.04-5.10, p=0.0002, I²=71%), and multivariate CSS (HR 1.62, 95% CI 1.22-2.15, p=0.33, I²=14%) when compared to non-intravesical techniques. Subgroup analysis revealed that this difference was primarily driven by the inferiority of the open extravesical approach. Endoscopic and non-endoscopic BCE demonstrated equivalent univariate and multivariate IVRFS, RFS, and CSS.

Conclusions: Open intravesical BCE is associated with superior oncologic outcomes when compared to non-intravesical techniques. This difference is primarily driven by the open intravesical approach's superiority to the open extravesical approach. Endoscopic BCE showed equivalent outcomes when compared to non-endoscopic approaches. Prospective randomized trials can shed further light on the optimal approach to BCE.