Unlike other forms of KSS, segmental ureterectomy (SU) allows for the complete removal of the compromised ureter while preserving the kidney, thereby offering a unique balance between organ preservation and radical excision. However, concerns persist regarding its oncological safety, as higher recurrence rates have been associated with this technique.
We conducted a systematic review and meta-analysis to comprehensively assess the oncologic and renal function outcomes of patients with UTUC who underwent SU compared to those treated with RNU.
Twenty-nine studies totaling 33,241 patients were included for analysis. SU was performed in 9,871 patients (29.7%), while 23,370 patients underwent RNU (70.3%). Subgroup analyses were conducted to evaluate oncological outcomes at 3- and 5-year follow-ups, where feasible, to minimize potential bias related to variations in follow-up durations.
Demographically, patients undergoing SU were slightly older and less likely to be female. A history of bladder cancer and smaller tumor size were more common in the SU group, while patients in the RNU group presented with more advanced disease and high-grade tumors. Positive lymph node status, preoperative estimated glomerular filtration rate (eGFR), positive surgical margins, and use of adjuvant chemotherapy were comparable between groups. However, neoadjuvant chemotherapy was more frequently administered in the RNU cohort.
Meta-analysis of oncological outcomes—abstracted from adjusted and unadjusted hazard ratios where available—revealed no significant differences between the procedures for both 3-year and 5-year cancer-specific survival, overall survival, recurrence-free survival, and metastasis-free survival.
Renal function outcomes consistently favored SU. Patients in this group showed higher postoperative eGFR and lower eGFR change—defined as the variation between baseline and last eGFR—across all time points up to 1-year follow-up. This is particularly relevant in light of the well-documented renal impairment associated with RNU, which has been shown to result in a median eGFR decline of up to 25%. Preservation of renal function is not only important for long-term health but also plays a critical role in maintaining eligibility for cisplatin-based adjuvant chemotherapy—many patients who might benefit from such treatment may no longer qualify after RNU due to loss of renal function.
While this meta-analysis has several limitations, we believe this study allows for an excellent segway for future randomized/prospective trials, which we could not identify through our exhaustive systematic search.
In conclusion, SU may be a valuable treatment option for patients with low-risk UTUC and carefully selected high-risk cases, as it may offer comparable oncologic outcomes to RNU while offering improved renal function preservation. Rigorous surveillance, as with all KSS approaches, remains essential to ensure oncologic control. Further high-quality clinical trials are needed to better delineate the role of SU and support more definitive treatment recommendations.
Written by: Alejandro Calvillo-Ramirez, MD, Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH
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