Utility and significance of ureteric frozen section analysis during radical cystectomy

Objective To assess the utility of routine frozen section analysis of ureters at the time of radical cystectomy (RC) for urothelial cancer (UC), and the long-term outcomes of adverse ureteric pathology. Patients and Methods Pathological data on 2 047 patients undergoing RC for UC with routine frozen section analysis of ureters (January 1971 to December 2009) were analysed. Univariate and multivariable logistic and Cox proportional hazards models were used to determine the risk of upper tract UC (UTUC) recurrence, local recurrence and overall survival in those identified as having adverse pathology (severe atypia/carcinoma in situ [CIS] or UC) at time of frozen section analysis. Results Adverse pathology was identified by frozen section analysis in 178 patients (8.6%). Frozen section analysis was found to have poor sensitivity in identifying adverse pathology (59.1%), which was improved in patients with preoperative CIS (68.0%). After a median (interquartile range) follow-up of 12.4 (1.9-10.1) years, 28 patients (1.4%) developed UTUC recurrence. There were no uretero-enteric anastomotic recurrences. Adverse pathology on frozen section analysis was associated with UTUC recurrence on univariate analysis (hazard ratio [HR] 6.2, 95% confidence interval [CI] 2.9-13.5), but 15/28 patients (54%) with UTUC recurrence had benign ureteric frozen section analysis on initial sectioning. Adverse pathology on frozen section analysis was not independently associated with the risk of local recurrence (HR 1.08, 95% CI 0.61-1.89) or overall survival (HR 1.12, 95% CI 0.94-1.35) in multivariate models. Conclusions Ureteric frozen section analysis has poor sensitivity and may be marginally improved in pre-existing CIS. UTUC recurrence is rare and can occur despite negative frozen section analysis. Our data question the utility of routine frozen section analysis of the distal ureteric margin at the time of RC.