Perioperative and Oncological Outcomes of Distal Ureterectomy for Upper Tract Urothelial Carcinoma (UTUC): A Multicentre Study from the European Association of Urology Non-muscle-invasive Bladder Cancer/UTUC Guidelines Panels with a Focus on Survival Free from Ipsilateral UTUC Recurrence

Background and objective: Distal ureterectomy (DU) is a kidney-sparing option for low-risk upper tract urothelial carcinoma (UTUC) and may be considered for selected high-risk cases. Long-term outcomes and recurrence predictors remain poorly defined. Our aim was to evaluate oncological outcomes of DU and identify preoperative predictors of disease recurrence, with a particular focus on ipsilateral upper tract recurrence (iUTR). Methods: This retrospective multicentre study included 450 patients with nonmetastatic UTUC in the distal ureter treated with DU and bladder cuff excision between 2010 and 2023. The primary endpoint was iUTR-free survival (iUTRFS). Secondary endpoints were intravesical recurrence-free survival (IVRFS), recurrence-free survival (RFS), cancer-specific survival (CSS), overall survival (OS), and perioperative outcomes. Survival outcomes were visualised using Kaplan-Meier curves, and multivariable Cox regression analyses were performed. Key findings and limitations: The 5-yr survival estimates were 82% for iUTRFS, 49% for IVRFS, 81% for RFS, 89% for CSS, and 72% for OS. IVRFS, iUTRFS, CSS, and OS did not significantly differ between the low-risk and high-risk groups. iUTR occurred in 16% of patients, with one in four of these cases arising after 5 yr. Salvage radical nephroureterectomy was performed in 10% of patients. Preoperative double-J stenting (hazard ratio [HR] 2.85, 95% confidence interval [CI] 1.11-7.30), tumour size (HR 1.04, 95% CI 1.01-1.07) and endoscopic bladder cuff management (HR 9.73, 95% CI 1.66-56.89) were independent predictors of iUTR. Perioperative complications were rare, with only 7% graded as high grade within 90 d. Limitations include the retrospective design, lack of centralised pathology review, and variability in surgical technique. Conclusions and clinical implications: DU provides favourable perioperative and long-term oncological outcomes and may also be appropriate for selected high-risk cases. iUTR is not uncommon, and prolonged upper tract follow-up is essential. Avoidance of preoperative stenting and endoscopic bladder cuff management may reduce the risk of iUTR.