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Background <p>The oncologic adequacy of distal ureterectomy (DU) versus radical nephroureterectomy (RNU) for nonmetastatic distal ureteral urothelial carcinoma remains debated, particularly in patients for whom renal preservation is clinically desirable.</p> Methods <p>A systematic review and meta-analysis of comparative studies was performed. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to February 27, 2026. A total of 229 records were identified, 14 full-text articles were assessed, and 6 studies were included. The primary outcome was a positive surgical margin. Secondary outcomes included intravesical recurrence, cancer-specific survival, lymph node metastasis, muscle-invasive disease (≥ pT2), and high-grade pathologic disease burden as a marker of baseline oncologic risk and treatment-selection balance. Random-effects models were used. Risk of bias was assessed with ROBINS-I, and certainty of evidence was evaluated using GRADE.</p> Results <p>A total of 6 comparative studies comprising 1,247 patients were included, of whom 588 underwent distal ureterectomy, and 659 underwent radical nephroureterectomy. DU was not associated with a significant difference in positive surgical margin compared with RNU (RR 1.24, 95% CI 0.64–2.43). Cancer-specific survival was also comparable (HR 0.97, 95% CI 0.72–1.29). No significant differences were observed for lymph node metastasis (RR 0.85, 95% CI 0.40–1.80), muscle-invasive disease (RR 0.96, 95% CI 0.86–1.08), or high-grade disease (RR 0.97, 95% CI 0.86–1.09). Intravesical recurrence was not significantly different in the primary pooled analysis (HR 1.36, 95% CI 0.89–2.07), although sensitivity analysis suggested a higher recurrence hazard after DU. Most outcomes were supported by very low to low certainty evidence.</p> Conclusions <p>In selected patients with nonmetastatic distal ureteral urothelial carcinoma, DU appears to preserve oncologic adequacy relative to RNU while offering a kidney-sparing surgical alternative. The main trade-off may be a higher risk of intravesical recurrence, underscoring the need for careful surveillance and individualized surgical decision-making.</p>

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Distal ureterectomy versus radical nephroureterectomy for nonmetastatic distal ureteral urothelial carcinoma: a GRADE-assessed systematic review and meta-analysis of comparative studies

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  • 发表日期：

    2026年5月29日

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  • Wajahat Mirza,
  • Khalid Hussain,
  • Maria Khalid,
  • Rao Nouman Ali,
  • Muhammad Bilal Moeen-Ud-Din,
  • Abdalla M. Hadhoud

摘要

Background

The oncologic adequacy of distal ureterectomy (DU) versus radical nephroureterectomy (RNU) for nonmetastatic distal ureteral urothelial carcinoma remains debated, particularly in patients for whom renal preservation is clinically desirable.

Methods

A systematic review and meta-analysis of comparative studies was performed. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to February 27, 2026. A total of 229 records were identified, 14 full-text articles were assessed, and 6 studies were included. The primary outcome was a positive surgical margin. Secondary outcomes included intravesical recurrence, cancer-specific survival, lymph node metastasis, muscle-invasive disease (≥ pT2), and high-grade pathologic disease burden as a marker of baseline oncologic risk and treatment-selection balance. Random-effects models were used. Risk of bias was assessed with ROBINS-I, and certainty of evidence was evaluated using GRADE.

Results

A total of 6 comparative studies comprising 1,247 patients were included, of whom 588 underwent distal ureterectomy, and 659 underwent radical nephroureterectomy. DU was not associated with a significant difference in positive surgical margin compared with RNU (RR 1.24, 95% CI 0.64–2.43). Cancer-specific survival was also comparable (HR 0.97, 95% CI 0.72–1.29). No significant differences were observed for lymph node metastasis (RR 0.85, 95% CI 0.40–1.80), muscle-invasive disease (RR 0.96, 95% CI 0.86–1.08), or high-grade disease (RR 0.97, 95% CI 0.86–1.09). Intravesical recurrence was not significantly different in the primary pooled analysis (HR 1.36, 95% CI 0.89–2.07), although sensitivity analysis suggested a higher recurrence hazard after DU. Most outcomes were supported by very low to low certainty evidence.

Conclusions

In selected patients with nonmetastatic distal ureteral urothelial carcinoma, DU appears to preserve oncologic adequacy relative to RNU while offering a kidney-sparing surgical alternative. The main trade-off may be a higher risk of intravesical recurrence, underscoring the need for careful surveillance and individualized surgical decision-making.