Segmental ureterectomy versus radical nephroureterectomy for middle and distal ureteral tumors associated with hydronephrosis: a comparative analysis of oncological outcomes and postoperative renal function.

BACKGROUND

Radical nephroureterectomy (RNU) is the standard for high-risk upper tract urothelial carcinoma but causes inevitable renal functional decline. We evaluated the oncological outcomes and renal preservation of segmental ureterectomy (SU) versus RNU specifically for middle and distal ureteral tumors associated with hydronephrosis.

METHODS

We retrospectively reviewed 139 patients (55 SU, 84 RNU) with middle or distal ureteral tumors and hydronephrosis treated between 2014 and 2024. Endpoints included overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and intravesical recurrence-free survival (IVRFS). Perioperative renal function was evaluated using estimated glomerular filtration rate (eGFR).

RESULTS

During a median follow-up of 40.6 months, baseline characteristics were well balanced between the SU and RNU groups after overlap weighting. Despite a high proportion of high-risk disease (77.9% ≥ T2, 59.2% high-grade), no significant differences existed between SU and RNU in OS (P = 0.969), CSS (P = 0.840), RFS (P = 0.957), or IVRFS (P = 0.941). Weighted Cox proportional hazards confirmed survival was dictated by tumor characteristics (stage, grade, length, lymph node involvement, surgical margins, vascular invasion and tumor necrosis), not surgical modality. Longitudinal mixed-effects analysis demonstrated that SU was associated with significantly higher postoperative eGFR compared with RNU across all follow-up intervals (P < 0.001).

CONCLUSIONS

For middle and distal ureteral tumors presenting with hydronephrosis, no statistically significant differences in long-term oncological outcomes were observed between SU and RNU within the current cohort. SU demonstrated higher postoperative eGFR values, suggesting a potential nephron-sparing advantage in carefully selected patients.