Significance of Distal Ureteral Margin at Radical Cystectomy for Urothelial Carcinoma

Purpose: Urothelial carcinoma develops from a diffusely susceptible mucosa and, thus, patients who undergo cystectomy are at risk for upper tract recurrence. Management of the distal ureter at cystectomy remains controversial and the impact of a sequential sectioning strategy remains unclear. Materials and Methods: We identified 1,397 patients who underwent radical cystectomy for nonmetastatic urothelial carcinoma from 1980 to 1998. All patients underwent frozen section analysis of the distal ureteral specimen. When positive, additional specimens were obtained. We evaluated the impact of a positive ureteral margin and the effect of ultimately obtaining a negative margin after sequential resection. Results: At last followup 432 patients (31%) had died of urothelial carcinoma a median of 1.8 years after cystectomy. Median followup in the 315 patients alive at last evaluation was 14.0 years. A total of 178 patients (12.7%) had a positive initial ureteral margin and only 31 (2.2%) had a positive final resection margin. Associations of margin status with overall and cancer specific survival were not statistically significant. Of 1,397 patients 69 (4.9%) experienced upper tract recurrence at a median of 3.1 years. Positive initial margin status and final margin status were associated with upper tract recurrence (p <0.001). Conclusions: Patients with positive ureteral margins at cystectomy are at increased risk for upper tract recurrence. With a serial sectioning strategy most positive initial margins can be converted to negative final margins. Patients who undergo conversion to a negative final margin with serial sectioning are at decreased risk for upper tract disease.