Distal ureterectomy versus radical nephroureterectomy for nonmetastatic distal ureteral urothelial carcinoma: a GRADE-assessed systematic review and meta-analysis of comparative studies

BACKGROUND: The oncologic adequacy of distal ureterectomy (DU) versus radical nephroureterectomy (RNU) for nonmetastatic distal ureteral urothelial carcinoma remains debated, particularly in patients for whom renal preservation is clinically desirable. METHODS: A systematic review and meta-analysis of comparative studies was performed. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to February 27, 2026. A total of 229 records were identified, 14 full-text articles were assessed, and 6 studies were included. The primary outcome was a positive surgical margin. Secondary outcomes included intravesical recurrence, cancer-specific survival, lymph node metastasis, muscle-invasive disease (≥ pT2), and high-grade pathologic disease burden as a marker of baseline oncologic risk and treatment-selection balance. Random-effects models were used. Risk of bias was assessed with ROBINS-I, and certainty of evidence was evaluated using GRADE. RESULTS: A total of 6 comparative studies comprising 1,247 patients were included, of whom 588 underwent distal ureterectomy, and 659 underwent radical nephroureterectomy. DU was not associated with a significant difference in positive surgical margin compared with RNU (RR 1.24, 95% CI 0.64-2.43). Cancer-specific survival was also comparable (HR 0.97, 95% CI 0.72-1.29). No significant differences were observed for lymph node metastasis (RR 0.85, 95% CI 0.40-1.80), muscle-invasive disease (RR 0.96, 95% CI 0.86-1.08), or high-grade disease (RR 0.97, 95% CI 0.86-1.09). Intravesical recurrence was not significantly different in the primary pooled analysis (HR 1.36, 95% CI 0.89-2.07), although sensitivity analysis suggested a higher recurrence hazard after DU. Most outcomes were supported by very low to low certainty evidence. CONCLUSIONS: In selected patients with nonmetastatic distal ureteral urothelial carcinoma, DU appears to preserve oncologic adequacy relative to RNU while offering a kidney-sparing surgical alternative. The main trade-off may be a higher risk of intravesical recurrence, underscoring the need for careful surveillance and individualized surgical decision-making.