Effect on postoperative survival of the status of distal ureteral margin: The necessity to achieve negative margins at the time of radical cystectomy

Background Despite several studies, the adequate management of positive distal ureter margins at the time of radical cystectomy (RC) remains controversial. Particularly, it is not clear whether the achievement of negative distal ureter margins at the intraoperative frozen sections (IFS) affects postoperative cancer-specific mortality (CSM). Methods In all, 1,447 consecutive patients treated with RC at a single center between January 1987 and August 2014 were considered. Multivariable (MVA) logistic regression analyses were used to determine predictors of positive IFS. MVA Cox regression analyses were used to test the effect on CSM of intraoperative conversion to negative margins. Results At IFS, 368 patients (25%) experienced at least 1 positive margin. Of these, a negative conversion of the margin at IFS occurred in 178 (48%) whereas 190 (52%) had a positive final ureteral margin. The mean follow-up was 95 months (median = 102). At MVA, history of carcinoma in situ (odds ratio = 6.40, P<0.001) was predictors of positive margin at IFS. At MVA, ureteral margins that were not converted to negative (hazard ratio = 1.92, P = 0.01) were associated with CSM but only in patients with negative soft tissue margin and without node metastases. Conclusions Achieving negative IFS margins may be associated with survival benefit in patients without residual bladder cancer after RC. Patients who recorded a history of carcinoma in situ before RC are at higher risk to incur positive ureteral margin at IFS and should be investigated during RC.