Is there still a role for ureteric frozen section analysis during radical cystectomy?

Objectives: To evaluate the utility of routine intra-operative frozen section analysis (iFSA) of distal ureteric margins during radical cystectomy (RC) for bladder cancer (BCa), focusing on diagnostic accuracy and oncological outcomes in a high-volume tertiary centre. Patients and Methods: We retrospectively identified 1081 patients with BCa treated with RC (2010–2024). Bilateral iFSA of the distal ureters was performed in all cases. Patients were stratified according to final distal ureteric margin status (positive vs negative); if positive, additional resections were attempted intra-operatively. Diagnostic concordance between iFSA and final pathology was calculated. Kaplan–Meier curves were used to assess 5-year upper urinary tract recurrence (UUTR) free-survival, overall survival (OS), and cancer-specific survival (CSS). Univariable logistic regression and multivariable logistic regression (MLR) models identified variables associated with positive margins. Results: Overall, 139 patients (12.9%) had positive distal ureteric margins at iFSA. The sensitivity and specificity of FSA were 98.6% and 99.5%, respectively. In MLR models, hydronephrosis (odds ratio [OR] 1.75, P = 0.014), T3–T4 stage (OR 2.48, P = 0.003), bladder carcinoma in situ (CIS; OR 7.94, P < 0.001) and trigonal tumour location (OR 4.85, P < 0.001) were independently associated with positive distal ureteric margins at iFSA. Positive margins were associated with increased risk of UUTR (5-year UUTR-free survival: 58% vs 78%; P = 0.038), worse OS (5-year OS: 48% vs 67%; P = 0.039), and worse CSS (5-year CSS: 60% vs 75%; P = 0.0018). Conclusion: Our study showed that iFSA of distal ureteric margins during RC for BCa provided excellent diagnostic performance and enabled cancer-free anastomosis. Our findings support iFSA, especially in patients with bladder CIS, trigonal tumours, or hydronephrosis, to guide intra-operative decisions and tailor postoperative surveillance.