Comparing oncological and perioperative outcomes of open versus laparoscopic versus robotic radical nephroureterectomy for the treatment of upper tract urothelial carcinoma: A multicenter, multinational, propensity score-matched analysis

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Conference Proceeding

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Eur Urol


Introduction & Objectives: The growth of minimally invasive methods for radical nephroureterectomy (RNU) has significantly changed the surgical treatment of upper tract urothelial carcinoma (UTUC). Laparoscopic and robotic RNU (LRNU and RRNU) increased during the last two decades while open RNU (ORNU) decreased. However, the current evidence regarding oncologic and perioperative outcomes between LRNU, RRNU and ORNU is weak. The aim of the study was to compare survival and perioperative outcomes between these approaches using a large, multicenter database.

Materials & Methods: Multi-institutional, retrospective study including high-risk non-metastatic UTUC patients who underwent RNU between 1990 - 2020. Multiple imputation by chained equations was used to impute missing data. Patients were divided into 3 groups based on their surgical treatment and were adjusted by 1:1:1 propensity score matching (PSM). The primary objective was to compare survival outcomes between surgical approaches with bladder recurrence-free survival (BRFS), recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) as primary endpoints. The secondary objective was to compare perioperative outcomes with intraoperative bloos loss, length of inpatient stay (LOIS), overall and major postoperative complications (MPC) as secondary endpoints.

Results: Of the 2434 patients included, 756 remained after PSM with 252 in each group. The three groups had similar clinico-pathological characteristics. The median follow-up was 32 months. Kaplan-Meier and log-rank tests showed similar RFS, CSS, OS between groups, while a better BRFS was found in favor of ORNU. In multivariable regression analyses, LRNU and RRNU were shown to be independent predictors of worse BRFS (HR 1.66, 95% CI 1.22- 2.28; p = 0.001 and HR 1.73, 95%CI 1.22- 2.47; p = 0.002 respectively). LRNU and RRNU were an independent predictor of shorter LOIS (beta -1.1, 95% CI -2.2- 0.02; p = 0.047 and beta -6.1, 95% CI -7.2- 5.0; p < 0.001, respectively) and less MPC (OR 0.5, 95% CI 0.31- 0.79; p = 0.003 and OR 0.27, 95% CI 0.16- 0.46; p < 0.001, respectively).

Conclusions: We could confirm previous findings that ORNU, LRNU and RRNU have comparable RFS, CSS and OS. However, LRNU and RRNU were shown to have a significantly worse BRFS, highlighting the need to improve the bladder-cuff technique and the importance of postoperative intravesical chemotherapy. LRNU and RRNU were independent predictors of shorter LOIS and less MPC.



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