Impact of Bladder Cuff Excision on Nephroureterectomy Outcomes for UTUC

Chandru P. Sundaram, MD, of Indiana University Department of Urology, and Katie S. Murray, DO, MS, of NYU Langone Urology and Bellevue Hospital, highlight the results of a large multi-institutional study involving robotic nephroureterectomy and bladder cuff excision for upper tract urothelial carcinoma (UTUC).

Dr. Sundaram explains the importance of bladder cuff excision in reducing bladder cancer recurrence while also noting the flexibility in treatment for older patients with comorbidities, emphasizing the advantages of robotic surgery in achieving better outcomes.

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Dr. Murray: Today, we are going to discuss UTUC, a subject that is always important for urologists, especially regarding the surgeries we perform for this rare disease. Due to its rarity, it’s sometimes difficult to conduct large studies to assess our practices. Dr. Sundaram has had the opportunity to work with a fantastic group, and he is here to share his recent research on nephroureterectomy, particularly focusing on the bladder cuff. I will let him take it from here.

Dr. Sundaram: Thank you very much, Dr. Murray. It is certainly a pleasure to be here with you. We had the opportunity to collaborate with 17 institutions across the globe, studying over 1,700 patients who underwent robotic nephroureterectomy for UTUC.

What we found was that patients who had the bladder cuff excised showed better outcomes in terms of bladder recurrence rates. However, there was no difference in overall survival, metastasis-free survival, or cancer-specific survival. So, the takeaway is that the gold standard of bladder cuff excision remains the best treatment option for patients undergoing robotic or open nephroureterectomy for this disease.

Dr. Murray: That is a very interesting finding and really reinforces what we have been practicing and teaching as urologists.

While you did not necessarily dive into it, when we talk about cancer outcomes, we often focus on overall and cancer-specific survival. But in this patient population, bladder recurrence-free survival is a particularly patient-centered outcome, which is crucial for us as urologists. Reducing the risk of bladder recurrences is not only important for patient quality of life but also from a financial perspective, since we have to scope these patients regularly in the clinic.

Dr. Sundaram: Absolutely, I fully agree. In fact, the bladder recurrence rate was 28% when the bladder cuff was not excised, compared to 23% when it was. So, there’s clearly a difference. But as we all know, not every patient is the same. For instance, older patients with multiple comorbidities might not be ideal candidates for prolonged surgery. In those cases, excising the bladder cuff may not be the best option, and we may need to accept a slightly higher risk of bladder recurrence in order to minimize perioperative morbidity and get the patient off the table more quickly.

Dr. Murray: That is an excellent point. As urologists, our goal is always to do what is best for the patient, and taking the bladder cuff when possible is certainly part of that. In my own experience, with modern robotic techniques, removing the cuff does not typically add significant comorbidity. However, in select patients—like those aged in the 80s or 90s with multiple health issues—your study suggests that it is reasonable to omit the formal cuff excision without compromising cancer-specific or overall survival.

Dr. Sundaram: That is a great point. In fact, in our study, 90% of patients did have a formal bladder cuff excised. Only 6% did not, while 4% had other techniques used, such as the pluck, intussusception, or stapling techniques. As you mentioned, these methods allow us to go down to the intramural portion of the ureter and staple across, reducing operating time without sacrificing patient outcomes.

Dr. Murray: Yes, and it is always exciting to see large-scale studies with thousands of patients in a rare disease like UTUC. That is a tremendous accomplishment. Congratulations! Before we wrap up, are there any other key points about this study or nephroureterectomy in general that you would like to highlight?

Dr. Sundaram: I think one important point is that the robotic approach allows us to excise the entire intramural portion of the ureter using an extravesical approach, which was not as easily accomplished with open surgery. In my opinion, the robotic approach not only replicates the open technique but actually improves upon it.

Dr. Murray: That is an excellent observation. I remember during training, doing open nephroureterectomies felt like revisiting pediatric surgery, with the extravesical versus intravesical reimplantation. From a training perspective, as newer surgeons enter the field, performing that dissection of the intramural tunnel down to the bladder cuff using a robotic extravesical approach is really valuable.