CONTEXT: Radical nephroureterectomy (RNU) with bladder cuff resection is the standard treatment in patients with high-risk upper tract urothelial cancer (UTUC). However, it is unclear which specific surgical technique may lead to improve oncological outcomes in term of intravesical recurrence (IVR) in patients with UTUC. OBJECTIVE: To evaluate the efficacy of surgical techniques and approaches of RNU in reducing IVR in UTUC patients. EVIDENCE ACQUISITION: Three databases were queried in January 2024 for studies analyzing UTUC patients who underwent RNU. The primary outcome of interest was the rate of IVR among various types of surgical techniques and approaches of RNU. EVIDENCE SYNTHESIS: Thirty-one studies, comprising 1 randomized controlled trial and 1 prospective study, were included for a systematic review and meta-analysis. The rate of IVR was significantly lower in RNU patients who had an early ligation (EL) of the ureter compared to those who did not (HR: 0.64, 95% CI: 0.44-0.94, p = 0.02). Laparoscopic RNU significantly increased the IVR compared to open RNU (HR: 1.28, 95% CI: 1.06-1.54, p < 0.001). Intravesical bladder cuff removal significantly reduced the IVR compared to both extravesical and transurethral bladder cuff removal (HR: 0.65, 95% CI: 0.51-0.83, p = 0.02 and HR: 1.64, 95% CI: 1.15-2.34, p = 0.006, respectively). CONCLUSIONS: EL of the affected upper tract system, ureteral management, open RNU, and intravesical bladder cuff removal seem to yield the lowest IVR rate in patients with UTUC. Well-designed prospective studies are needed to conclusively elucidate the optimal surgical technique in the setting of single post-operative intravesical chemotherapy.

Collegium Medicum Faculty of Medicine WSB University Dąbrowa Górnicza Poland

Department of Biomedical Sciences Humanitas University Pieve Emanuele Italy

Department of Surgery S H Ho Urology Centre The Chinese University of Hong Kong Hong Kong SAR China

Department of Urology 2nd Faculty of Medicine Charles University Prague Czechia Czechia

Department of Urology Comprehensive Cancer Center Medical University Vienna Vienna General Hospital Währinger Gürtel 18 20 Vienna A 1090 Austria

Department of Urology Dentistry and Pharmaceutical Sciences Okayama University Graduate School of Medicine Okayama Japan

Department of Urology James Buchanan Brady Urological Institute Johns Hopkins University School of Medicine 600 North Wolfe Street Park 213 Baltimore MD 21287 USA

Department of Urology Jikei University School of Medicine Tokyo Japan

Department of Urology Semmelweis University Budapest Hungary

Department of Urology Shariati Hospital Tehran University of Medical Sciences Tehran Iran

Department of Urology Shimane University Faculty of Medicine Shimane Japan

Department of Urology Spitalul Clinic Judetean Murures University of Medicine Science and Technology of Targu Mures Pharmacy Mures Romania

Department of Urology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Urology University of Texas Southwestern Medical Center Dallas TX USA

Department of Urology Weill Cornell Medical College New York NY USA

Division of Urology Department of Special Surgery The University of Jordan Amman Jordan

Division of Urology Department of Surgical Sciences Molinette Hospital University of Turin Turin Italy

Institute for Urology and Reproductive Health Sechenov University Moscow Russia

Karl Landsteiner Institute of Urology and Andrology Vienna Austria

Research Center for Evidence Medicine Urology Department Tabriz University of Medical Sciences Tabriz Iran

Sorbonne University AP HP Pitie Salpetriere Hospital GRC 5 Predictive Onco Uro Urology PARIS F 75013 France

Unit of Oncologic Minimally Invasive Urology and Andrology Department of Experimental and Clinical Medicine Careggi Hospital University of Florence Florence Italy

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