Abstract
ABSTRACT Objective To summarise the currently available literature and analyse available results of the outcome of intraoperative frozen-section analysis (FSA) on upper urinary tract recurrence (UUTR) after radical cystectomy (RC). Materials and methods A systematic review of the literature was performed according to the Cochrane Reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles discussing ureteric FSA with RC were identified. Results The literature search yielded 21 studies, on which the present analysis was done. The studies were published between 1997 and 2019. There were 10 010 patients with an age range between 51 and 95 years. Involvement of the ureteric margins was noted in 2–9% at RC. The sensitivity and specificity of FSA were ~75% and 99%, respectively. Adverse pathology on FSA and on permanent section, prostatic urothelial carcinoma involving the stroma but not prostatic duct, and ureteric involvement on permanent section were all more likely to develop UUTR. Neither evidence of ureteric involvement nor ureteric margin status on permanent section were significant predictors of overall survival. Conclusion Routine FSA is mandatory for a tumour-free uretero–enteric anastomosis and is predictive of UUTR. To lower the UUTR, FSA is not necessary if the ureters are resected at the level where they cross the common iliac vessels. FSA is indicated whenever the surgeon encounters findings suspicious of malignancy, e.g. ureteric obstruction, periureteric fibrosis, diffuse carcinoma in situ, induration or frank tumour infiltration of the distal ureter is discovered unexpectedly during surgery, and prostatic urethral involvement. Abbreviations CIS: carcinoma in situ; FSA: frozen-section analysis; HR: hazard ratio; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; (UT)UC: (upper tract) urothelial carcinoma; UUT(R): upper urinary tract (recurrence)
Highlights
Bladder cancer represents the fifth most common malignancy in the Western world, with an incidence of 80 470 in 2019 and a mortality rate of 17 670 per year in the USA alone [1,2].The incidence of upper urinary tract recurrence (UUTR) after radical cystectomy (RC) is reportedly 2.4–6.6%, and is associated with multiple clinical and pathological risk factors including tumour multifocality, pathological stage, presence of carcinoma in situ (CIS), and ureteric and urethral involvement [3,4,5,6].To identify ureteric margin status, and ureteric involvement, intraoperative frozen-section analysis (FSA) during RC and serial sectioning of the distal ureter is performed
The validity of this approach in improving UUTR outcomes is controversial, with several publications questioning the accuracy of FSA and the feasibility of achieving uninvolved ureteric margins by sequential ureteric sectioning in light of the relative rarity of UUTR after RC [7]
We aimed to conduct a systematic review of the literature to evaluate the accuracy of FSA to detect malignant ureteric margins at the time of RC and to determine the impact of final margin status obtained by a sequential sectioning strategy on the risk of UUTR
Summary
To identify ureteric margin status, and ureteric involvement, intraoperative frozen-section analysis (FSA) during RC and serial sectioning of the distal ureter is performed The validity of this approach in improving UUTR outcomes is controversial, with several publications questioning the accuracy of FSA and the feasibility of achieving uninvolved ureteric margins by sequential ureteric sectioning in light of the relative rarity of UUTR after RC [7]. To this end, we aimed to conduct a systematic review of the literature to evaluate the accuracy of FSA to detect malignant ureteric margins at the time of RC and to determine the impact of final margin status obtained by a sequential sectioning strategy on the risk of UUTR
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