Is frozen section analysis of ureteral margins at time of radical cystectomy useful?

The clinical utility of intraoperative frozen section analysis (FSA) of ureters at the time of radical cystectomy (RC) for urothelial cancer (UC) remains controversial and subject to considerable debate. Potential advantages include intraoperative detection of carcinoma in situ (CIS) or overt malignancy and directed ureteral sectioning to achieve negative margins to reduce anastomotic recurrence. The information gained at the time of FSA may be useful for risk-adapted upper tract surveillance. To critically assess the utility of FSA with respect to these potential advantages, we review the operating characteristics of FSA as a diagnostic test, the relationship between upper tract urothelial carcinoma (UTUC) recurrence and abnormal FSA, and the overall evidence for FSA on oncological end points and cost-effectiveness. Taken together, the weight of evidence suggests that while FSA is a reasonable diagnostic test, its utility has been recently questioned, and prospective study is warranted. There is a need to quantify the risk reduction in anastomotic recurrence in light of the cost-effectiveness of FSA compared to the alternative of only performing permanent analysis of proximal ureteral margins. Given the low rates of UTUC recurrence reported in the literature, the weak association between FSA and these recurrences, and mortality in retrospective studies, the clinical impact of reducing UTUC recurrence by FSA must continue to be critically evaluated.