Open bladder cuff excision versus pluck technique in nephroureterectomy for UTUC: postoperative and oncological outcomes from an Australian tertiary hospital.

Abstract

Introduction & Objectives: Nephroureterectomy (NU) requires removal of the intramural ureter and bladder cuff, typically via an open bladder cuff excision or the pluck (endoscopic) technique. Australian data remains limited. Herein, this study endeavours to compare postoperative and oncological outcomes between techniques within an Australian cohort. Method(s): This retrospective study included patients who underwent NU for histologically confirmed UTUC at an Australian tertiary hospital from 2010 to 2022. Patient-, tumour-, and treatmentrelated variables and postoperative complications (length of stay, ICU admission, 30/90-day readmission, and Clavien-Dindo >= III complications) were extracted. Group comparison's used Fisher's exact test, Welch's t test, and Mann-Whitney U test. Overall survival (OS), cancer-specific survival (CSS), and local-recurrence free survival (LRFS) were analysed using Cox models stratified by index tumour location (pelvicalyceal/ureteric/multifocal) and adjusted for age, tumour grade, stage (as events per variable permitted). Proportional hazards were assessed using Schoenfeld residuals. Kaplan-Meier (KM) curves and location-stratified logrank tests provided unadjusted milestones. Median follow up was estimated by reverse KM. Result(s): Among 88 eligible patients, 66 underwent open bladder cuff excision while 22 underwent pluck. Median follow-up was 7.7 years (95% CI: 5.4-8.9). Consistent with common practice patterns, ureteric tumours were more frequently managed with open cuff excision (53.0% vs 4.6%, P < 0.001). Proportion of high-grade tumours trended higher in pluck (77.3% vs 53.0%, P = 0.050). Operative time was significantly longer in the open group (325 min vs 279 min, P = 0.019); while postoperative complication rates did not differ. Overall, there were a total of 30 deaths, 15 cancer-specific deaths, and 32 local-recurrence events. Univariate Cox analysis suggested higher hazards with pluck for OS and LRFS. However, after stratifying by location and adjusting for covariates, effects were notably attenuated (see Table 1). PH was violated for technique in OS and LRFS; HRs are interpreted as time-averaged. Accordingly. We also present unadjusted 1/3/5-year milestone estimates with locationstratified log-rank tests (see Table 2). Conclusion(s): In this Australian cohort, pluck technique was associated with shorter operative times without increased postoperative complication rates. After stratifying by location and adjusting for key covariates, no significant differences were observed in OS, CSS, or LRFS. The attenuation of crude hazards indicates that casemix - particularly tumour location -rather than surgical technique itself, explained much of the unadjusted difference. Larger, multicentre studies with better within-location overlap is needed to determine whether any location-specific effect of technique exists.