Laparoscopic Versus Open Nephroureterectomy in Muscle-Invasive Upper Tract Urothelial Carcinoma: Subanalysis of the Multi-Institutional National Database of the Japanese Urological Association

Laparoscopic Versus Open Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-Analysis of Propensity-Score Matched Studies

BACKGROUND

The effectiveness of laparoscopic nephroureterectomy (LNU) vs open nephroureterectomy (ONU) for upper tract urothelial carcinoma (UTUC) is unclear.

METHODS

We conducted a meta-analysis of studies based on propensity score-matched cohorts to compare the surgical and oncological outcomes of LNU and ONU in UTUC patients. A literature search was conducted on PubMed, Embase, and Cochrane Library until July 12, 2023. The Newcastle-Ottawa Scale was utilized to assess the quality of eligible studies. Measurements of surgical and oncological outcomes were extracted and pooled including mean difference (MD), risk ratio (RR), hazard ratios (HR), and 95% confidence intervals (CI).

RESULTS

Five high-quality retrospective studies were included, totaling 6422 patients; 2080 (32.4%) underwent LNU, and 4342 (67.6%) underwent ONU. With respect to surgical outcomes, patients in the LNU group experienced less estimated blood loss and had shorter hospital stay than those in the ONU group, but there was no significant difference in complication rates and operation time. In regard to oncological outcomes, there were no significant differences between the LNU and ONU groups in 3-year overall survival (OS) and cancer-specific survival (CSS). However, 3-year intravesical recurrence free survival (IVRFS) was worse in the LNU group compared to the ONU group.

CONCLUSION

LNU was associated with less estimated blood loss and shorter hospital stays than ONU, but there were no differences in OS and CSS between the surgical modalities. Nonetheless, LNU might result in poorer IVRFS than ONU.

Comparing Oncological Outcomes and Surgical Complications of Hand-Assisted, Laparoscopic and Robotic Nephroureterectomy for Upper Tract Urothelial Carcinoma

Purpose

This study aimed to compare the oncological outcomes and surgical complications of patients with upper tract urothelial carcinoma (UTUC) treated with different minimally invasive techniques for nephroureterectomy.

Methods

From the updated data of the Taiwan UTUC Collaboration Group, a total of 3,333 UTUC patients were identified. After excluding ineligible cases, we retrospectively included 1,340 patients from 15 institutions who received hand-assisted laparoscopic nephroureterectomy (HALNU), laparoscopic nephroureterectomy (LNU) or robotic nephroureterectomy (RNU) between 2001 and 2021. Kaplan-Meier estimator and Cox proportional hazards model were used to analyze the survival outcomes, and binary logistic regression model was selected to compare the risks of postoperative complications of different surgical approaches.

Results

Among the enrolled patients, 741, 458 and 141 patients received HALNU, LNU and RNU, respectively. Compared with RNU (41.1%) and LNU (32.5%), the rate of lymph node dissection in HALNU was the lowest (17.4%). In both Kaplan-Meier and univariate analysis, the type of surgery was significantly associated with overall and cancer-specific survival. The statistical significance of surgical methods on survival outcomes remained in multivariate analysis, where patients undergoing HALNU appeared to have the worst overall (p = 0.007) and cancer-specific (p = 0.047) survival rates among the three groups. In all analyses, the surgical approach was not related to bladder recurrence. In addition, HALNU was significantly associated with longer hospital stay (p = 0.002), and had the highest risk of major Clavien-Dindo complications (p = 0.011), paralytic ileus (p = 0.012), and postoperative end-stage renal disease (p <0.001).

Conclusions

Minimally invasive surgery can be safe and feasible. We proved that compared with the HALNU group, the LNU and RNU groups have better survival rates and fewer surgical complications. It is crucial to uphold strict oncological principles with sophisticated technique to improve outcomes. Further prospective studies are needed to validate our findings.

Laparoscopic compared with open nephroureterectomy in upper urinary tract urothelial carcinoma: A systemic review and a meta-analysis

BACKGROUND

We performed a meta-analysis to evaluate the effects of open nephroureterectomy compared with laparoscopic nephroureterectomy on postoperative results in upper urinary tract urothelial carcinoma subjects.

METHODS

A systematic literature search up to January 2021 was done and 36 studies included 23 013 subjects with upper urinary tract urothelial carcinoma at the start of the study; 8178 of them were laparoscopic nephroureterectomy, and 14 835 of them were open nephroureterectomy. They were reporting relationships between the efficacy and safety of open nephroureterectomy compared with laparoscopic nephroureterectomy in the treatment of upper urinary tract urothelial carcinoma. We calculated the odds ratio (OR) or the mean difference (MD) with 95% confidence intervals (CIs) to assess the efficacy and safety of open nephroureterectomy compared with laparoscopic nephroureterectomy in the treatment of upper urinary tract urothelial carcinoma using the dichotomous or continuous method with a random or fixed-effect model.

RESULTS

Laparoscopic nephroureterectomy in subjects with upper urinary tract urothelial carcinoma was significantly related to longer operation time (MD, 43.90; 95% CI, 20.91-66.90, P < .001), shorter hospital stay (MD, -1.71; 95% CI, -2.42 to -1.00, P < .001), lower blood loss (MD, -133.82; 95% CI, -220.92 to -46.73, P = .003), lower transfusion need (OR, 0.56; 95% CI, 0.47-0.67, P < .001) and lower overall complication (OR, 0.79; 95% CI, 0.70-0.90, P < .001) compared with open nephroureterectomy. However, no significant difference was found between laparoscopic nephroureterectomy and open nephroureterectomy in subjects with upper urinary tract urothelial carcinoma in 2-5-years recurrence-free survival (OR, 0.90; 95% CI, 0.69-1.18, P = .46), 2-5-years cancer-specific survival (OR, 0.94; 95% CI, 0.69-1.28, P = .68) and 2-5-years overall survival (OR, 1.31; 95% CI, 0.91-1.87, P = .15).

CONCLUSIONS

Laparoscopic nephroureterectomy in subjects with upper urinary tract urothelial carcinoma may have a longer operation time, shorter hospital stay, lower blood loss, transfusion need and overall complication compared with open nephroureterectomy. Further studies are required to validate these findings.

Open Nephroureterectomy Compared to Laparoscopic in Upper Urinary Tract Urothelial Carcinoma: A Meta-Analysis

Background: In this meta-analysis, we will focus on evaluating the effects of open nephroureterectomy compared with laparoscopic nephroureterectomy on postoperative results in upper urinary tract urothelial carcinoma subjects.

Methods: A systematic literature search up to January 2021 was performed, and 36 studies included 23,013 subjects with upper urinary tract urothelial carcinoma at the start of the study; of them, 8,178 were laparoscopic nephroureterectomy, and 14,835 of them were open nephroureterectomy. They were reporting relationships between the efficacy and safety of open nephroureterectomy compared with laparoscopic nephroureterectomy in the treatment of upper urinary tract urothelial carcinoma. We calculated the odds ratio (OR) or the mean difference (MD) with 95% CIs to evaluate the efficacy and safety of open nephroureterectomy compared with laparoscopic nephroureterectomy in the treatment of upper urinary tract urothelial carcinoma using the dichotomous or continuous method with a random or fixed-effect model.

Results: Laparoscopic nephroureterectomy in subjects with upper urinary tract urothelial carcinoma was significantly related to longer operation time (MD, 43.90; 95% CI, 20.91–66.90, p < 0.001), shorter hospital stay (MD, −1.71; 95% CI, −2.42 to −1.00, p < 0.001), lower blood loss (MD, −133.82; 95% CI, −220.92 to −46.73, p = 0.003), lower transfusion need (OR, 0.56; 95% CI, 0.47–0.67, p < 0.001), and lower overall complication (OR, 0.79; 95% CI, 0.70–0.90, p < 0.001) compared with open nephroureterectomy.

However, no significant difference was found between laparoscopic nephroureterectomy and open nephroureterectomy in subjects with upper urinary tract urothelial carcinoma in 2–5 years recurrence-free survival (OR, 0.90; 95% CI, 0.69–1.18, p = 0.46), 2–5 years cancer-specific survival (OR, 0.94; 95% CI, 0.69–1.28, p = 0.68), and 2–5 years overall survival (OR, 1.31; 95% CI, 0.91–1.87, p = 0.15).

Conclusion: Laparoscopic nephroureterectomy in subjects with upper urinary tract urothelial carcinoma may have a longer operation time, shorter hospital stay, and lower blood loss, transfusion need, and overall complication compared to open nephroureterectomy. Further studies are required to validate these findings.

Comparing oncological outcomes of laparoscopic vs open radical nephroureterectomy for the treatment of upper tract urothelial carcinoma: A propensity score-matched analysis

Objectives

To compare oncological outcomes of open (ORNU) and laparoscopic radical nephroureterectomy (LRNU) after controlling for preoperative patient-derived factors.

Patients and methods

We evaluated a multi-institutional collaborative database composed of 3984 patients diagnosed with upper tract urothelial carcinoma (UTUC) treated with RNU between 2006 and 2018. To adjust for potential selection bias, propensity score matching adjusted for age, gender and American society Anesthesiology (ASA) score was performed with one ORNU patient matched to one LRNU patient. Uni- and multivariable Cox regression evaluating the risk of overall recurrence, cancer-specific mortality (CSM) and overall mortality (OM) in the overall population and after propensity matching were performed.

Results

In total, 3984 patients underwent RNU, of these 3227 (81%) patients were treated with ORNU and 757 (19%) patients with LRNU. Within a median follow-up of 62 months, 1276 recurrences, 844 CSMs and 1128 OMs were recorded. On multivariable analyses, the LRNU approach was associated with an increased risk of overall recurrence (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.03–1.54; P = 0.02), but on the other hand LRNU was associated with a protective effect on CSM (HR 0.74, 95% CI 0.56–0.98; P = 0.04). After propensity matching analyses adjusted for age, gender and ASA score, 757 patients treated with LRNU and 757 patients treated with ORNU were available for the analyses. On multivariable Cox regression, LRNU vs ORNU was not associated with any difference in overall recurrence (P = 0.08), CSM (P = 0.1) or OM (P = 0.9).

Conclusion

Our present data suggest that even if the type of approach to RNU was associated with different survival outcomes considering the overall population, this difference vanished when adjusted for potential confounders in propensity matching analyses. Therefore, we found that LRNU is not inferior to the ORNU approach for the treatment of UTUC.

Abbreviations

ASA: American Society of Anesthesiology; CIS: carcinoma in situ; CSM: cancer-specific mortality; HR: hazard ratio; IQR: interquartile range; LN: lymph node; LNI: lymph node invasion; LVI: lymphovascular invasion; OM: overall mortality; pT: pathological tumour stage; RCT: randomised controlled trial; (L)(O)RNU: (laparoscopic) (open) radical nephroureterectomy; UTUC: upper tract urothelial carcinoma

A New Surgical Technique of Combination Retroperitoneal with Transperitoneal Laparoscopic Nephroureterectomy in a Single Position and Comparative Outcomes

Background

The traditional surgical treatment for upper urinary tract urothelial carcinoma (UTUC) is time-consuming owing to changing the surgical position and larger surgical trauma because of open surgery in handling the distal ureter. Therefore, we created a new surgical technique of combination retroperitoneal with transperitoneal (CRT) laparoscopic nephroureterectomy (LNU) in a single position and here report our early outcomes.

Methods

From January 2017 to December 2019, a total of 106 patients underwent LNU by a single surgeon at our department, of whom 50 patients underwent standard technique and 56 patients underwent CRT technique. Relevant clinical data were collected including each patient’s characteristics, surgical outcomes, and follow-up results. A comparative analysis between standard LNU cases and CRT LNU cases was performed.

Results

LNU was performed successfully on all 106 patients. There was no significant difference in patients’ characteristics. Compared to the standard group, patients in the CRT group had shorter operative time (P=0.001), less estimated blood loss (EBL) (P<0.001), lower visual analogue scale (VAS) pain score (P=0.020) and less scarring (P=0.013). The median time of surgical drain stay decreased from 5 to 2 days (P=0.004) and median hospital stay after surgery decreased from 5 to 3 days (P=0.001). The complication rates did not show statistical differences between the two groups within the first 30 days postoperatively (P=0.263). For the long-term complications, the incidence of abdomen bulge or incisional hernia in the CRT group was less than that in the standard group (P<0.001).

Conclusion

The CRT technique, which combines both the advantages of retroperitoneal and transperitoneal approaches, is a more minimally invasive, simplified and effective way to perform the LNU.

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique

BACKGROUND

Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative "trifecta."

METHODS

Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage.

RESULTS

In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease.

CONCLUSIONS

Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.

Long-Term Oncologic Outcomes of Laparoscopic Versus Open Radical Nephroureterectomy for Patients with T3N0M0 Upper Tract Urothelial Carcinoma: A Multicenter Cohort Study with Adjustment by Propensity Score Matching

BACKGROUND

This study aimed to investigate the long-term oncologic outcomes of laparoscopic radical nephroureterectomy (LRNU) and open radical nephroureterectomy (ORNU) for patients with clinical and pathologic T3N0M0 upper tract urothelial carcinoma (UTUC).

METHODS

Among 375 UTUC patients who underwent radical nephroureterectomy, this study identified 144 pT3N0M0 patients as cohort 1 after propensity score (PS) matching. Among 399 UTUC patients, the study identified 110 cT3N0M0 patients as cohort 2 after PS matching. Oncologic outcomes such as intravesical recurrence-free survival (IVRFS) and cancer-specific survival (CSS) were assessed by multivariate Cox's regression analysis.

RESULTS

Cohort 1 of pT3N0M0 UTUC had 3-year CSS and IVRFS rates of 67.9 and 52.7%, respectively, in the LRNU group, which were significantly lower than in the ORNU group (81.4%, p = 0.039 and 71.6%, p = 0.046). The multivariate Cox's regression analysis identified the type of surgical approach (LRNU vs. ORNU) as one of the independent prognostic factors for CSS (hazard rate [HR], 1.88, p = 0.043) and IVRFS (HR, 1.75, p = 0.049). Cohort 2 of cT3N0M0 UTUC had 3-year CSS and IVRFS rates of 48.5 and 41.4%, respectively, in the LRNU group, which were significantly lower than in the ORNU group (65.8%, p = 0.049 and 67.2%, p = 0.047), and the type of surgical approach (LRNU vs. ORNU) remained as one of the independent prognostic factors for CSS and IVRFS.

CONCLUSIONS

Based on clinical and pathologic T3N0M0 UTUC populations after PS adjustments, LRNU resulted in poorer CSS and IVRFS than ORNU.

Retroperitoneal laparoscopic nephroureterectomy with distal and intramural ureter resection for a tuberculous non - functional kidney

Objective:

To evaluate the safety and feasibility of total retroperitoneal laparoscopic nephroureterectomy with urinary-bladder junction resection for a tuberculous nonfunctional kidney.

Materials and Methods:

A total of 27 individuals diagnosed with unilateral nonfunctional kidney secondary to tuberculosis were treated between June 2011 and June 2015. All patients had normal renal function on the contralateral side and underwent the standard four-drug anti-tuberculosis treatment for at least four weeks before surgery. Total retroperitoneal laparoscopic nephroureterectomy was performed in all patients, and the urinary-bladder junction of distal ureter was managed using different auto-suture techniques.

Results:

Nineteen male and 8 female patients with an average age of 47.3 years (range, 36-64 years) underwent surgery. All the operations were successfully performed without conversion. The median operative time was 109.3 min (range, 75-138 min), the median blood loss was 157.5 mL (range, 70-250 mL), and the median hospitalization time was 3.7 days (range, 3-6 days). No serious perioperative complications occurred. Anti-tuberculosis chemotherapy was prescribed to all patients, with the entire course of treatment lasting six months. No recurrence of tuberculosis of the bladder or the contralateral kidney was observed during the median follow-up period of 26.7 months (range, 6-54 months).

Conclusion:

Retroperitoneal laparoscopic nephroureterectomy with urinary-bladder junction resection is a safe and feasible approach for the treatment of tuberculous non-functional kidneys.

Laparoscopic versus open nephroureterectomy for upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of laparoscopic nephroureterectomy (LNU) and open nephroureterectomy (ONU) for the treatment of upper urinary tract urothelial carcinoma (UTUC).

METHODS

PubMed, Embase, and Cochrane databases were selected for systematic review of trials that compared outcomes of LNU and ONU. Meta-analysis was performed using RevMan 5.3 and STATA 13.0 software.

RESULTS

LNU was associated with longer operation time (P < .001), shorter hospital stay (P < .001), less blood loss (P = .006) and lower rate of transfusion (P < .001). The occurrence of complications, including minor (P = .52), major (P = .21) and total complications (P = .19) were similar between LNU and ONU. There was no significant difference in the rate of 5-year recurrence-free survival (P = .90), 5-year cancer-specific survival (P = .12), and 5-year overall survival (P = .11) as well as 2-year RFS (P = .84), 2-year CSS (P = .86), and 2-year OS (P = .25).

CONCLUSION

Our results indicated that LNU is a safe and effective method to treat UTUC. Given the limitations of this study, further multicenter, randomized trials are required to confirm these findings.

Risk-stratified surveillance protocol improves cost-effectiveness after radical nephroureterectomy in patients with upper tract urothelial carcinoma

Objectives

To develop a surveillance protocol with improved cost-effectiveness after radical nephroureterectomy (RNU), as the cost-effectiveness of oncological surveillance after RNU remains unclear.

Results

Of 426 patients, 109 (26%) and 113 (27%) experienced visceral and intravesical recurrences, respectively. The pathology-based protocol found significant differences in recurrence-free survival in the visceral recurrence but not in the intravesical recurrence. The medical costs per visceral recurrence detected were high, especially in normal-risk (≤ pT2N0, LVI-, SM-) patients. We developed a risk score associated with visceral recurrence using Cox regression analysis. The risk score-based protocol was significantly more cost-effective than the pathology-based protocol. Estimated cost differences reached $747,929 per recurrence detected, a suggested 55% reduction.

Materials and Methods

We retrospectively evaluated 426 patients with RNU for upper tract urothelial carcinoma (UTUC) without distant metastasis at 4 hospitals. Patients with routine oncological follow-up were stratified into normal-, high- and very high-risk groups according to a pathology-based protocol utilizing pathological stage, lymphovascular invasion (LVI) and surgical margin (SM). Cost-effectiveness of the pathology-based protocol was evaluated, and a risk score-based protocol was developed to optimize cost-effectiveness. Risk scores were calculated by summing up risk factors independently associated with recurrence-free survival. Patients were stratified by low-, intermediate- and high-risk score. Estimated cost per recurrence detected by pathology-based and risk score-based protocols was compared.

Conclusions

A risk score-stratified surveillance protocol has the potential to reduce over investigation during follow-up, making surveillance more cost-effective.

Oncologic outcomes for open and laparoscopic radical nephroureterectomy in patients with upper tract urothelial carcinoma

BACKGROUND

Oncologic benefits of laparoscopic radical nephroureterectomy (LNU) are unclear. We aimed to evaluate the impact of surgical approach for radical nephroureterectomy on oncologic outcomes in patients with locally advanced upper tract urothelial carcinoma (UTUC).

METHODS

Of 426 patients who underwent radical nephroureterectomy at five medical centers between February 1995 and February 2017, we retrospectively investigated oncological outcomes in 229 with locally advanced UTUC (stages cT3-4 and/or cN+). The surgical approach was classified as open nephroureterectomy (ONU) or LNU, and oncologic outcomes, including intravesical recurrence-free survival (RFS), visceral RFS, cancer-specific survival (CSS), and overall survival (OS), were compared between the groups. The inverse probability of treatment weighting (IPTW)-adjusted Cox-regression analyses was performed to evaluate the impact of LNU on the prognosis.

RESULTS

Of the 229 patients, 48 (21%) underwent LNU. There were significant differences in patient backgrounds, including preoperative renal function, lymph-node involvement, lymphovascular invasion, and surgical margins, between the groups. Before the background adjustment, intravesical RFS, visceral RFS, CSS, and OS were significantly inferior in the ONU group than in the LNU group. However, in the IPTW-adjusted Cox-regression analysis, no significant differences were observed in intravesical RFS (hazard ratio [HR], 0.65; P = 0.476), visceral RFS (HR, 0.46; P = 0.109), CSS (HR, 0.48; P = 0.233), and OS (HR, 0.40; P = 0.147).

CONCLUSION

Surgical approaches were not independently associated with prognosis in patients with locally advanced UTUC.

Detecting asymptomatic recurrence after radical nephroureterectomy contributes to better prognosis in patients with upper urinary tract urothelial carcinoma

Background

The prognostic benefit of regular follow-up to detect asymptomatic recurrence after radical nephroureterectomy (RNU) remains unclear. We aimed to assess whether regular follow-up to detect asymptomatic recurrence after RNU improves patient survival.

Materials and Methods

We retrospectively analysed 415 patients who underwent RNU for upper tract urothelial carcinoma at four hospitals between January 1995 and February 2017. All patients had regular follow-up examinations after RNU including urine cytology, blood biochemical tests, and computed tomography. We investigated the first site and date of tumor recurrence. Overall survivals of patients who developed recurrence, stratified by mode of recurrence (asymptomatic vs. symptomatic group), were estimated using the Kaplan-Meier method with the log-rank test. Cox proportional hazards regression analysis was performed using inverse probability of treatment weighting (IPTW) to evaluate the impact of the mode of recurrence on survival.

Results

Of the 415 patients, 108 (26%) experienced disease recurrences after RNU. Of these, 62 (57%) were asymptomatic and 46 (43%) were symptomatic at the time of diagnosis. The most common recurrence site and symptom were lymph nodes and pain, respectively. Overall survival after RNU and time from recurrence to death in the asymptomatic group were significantly longer than that in the symptomatic group. Multivariate Cox regression analysis showed that symptomatic recurrence was an independent risk factor for overall survival after RNU and survival from recurrence to death.

Conclusions

Routine oncological follow-up for detection of asymptomatic recurrence contributes to a better prognosis after RNU.

Standardized and Simplified Retroperitoneal Lymph Node Dissection During Retroperitoneal Laparoscopic Radical Nephroureterectomy for Urothelial Carcinoma of the Upper Ureter or Renal Pelvis: En Bloc Resection Technique

OBJECTIVE

To describe our en bloc technique of retroperitoneal lymph node dissection (RPLND) during retroperitoneal laparoscopic radical nephroureterectomy for upper urinary tract urothelial carcinoma and evaluate perioperative outcomes.

METHODS

From 2002 to 2015, 114 patients with urinary tract urothelial carcinoma located at the pelvis or upper or middle ureter underwent retroperitoneal laparoscopic radical nephroureterectomy at 2 institutions. Performance of RPLND began in February 2009. The template of RPLND included the renal hilar and para-aortic lymph nodes (left side) and the renal hilar, paracaval, retrocaval, and intra-aortocaval lymph nodes (right side). After incising Gerota fascia longitudinally, the aorta (left side) or inferior vena cava (right side) was exposed, and the lymphatic and surrounding fatty tissue in the template and kidney was dissected in a single monoblock. Preoperative data were compared between the RPLND and the no-RPLND groups using propensity score matching.

RESULTS

In total, 32 matched pairs were evaluated. RPLND was successfully accomplished without open conversion in all cases. The operative time in the RPLND group was approximately 100 minutes longer than that in the no-RPLND group, but there was no significant difference in the blood loss volume or complication rate. The pathologic stages were similar in both groups. The mean number of retrieved lymph nodes was 10.7 (range 3-27), and lymph node metastasis was detected in 5 (16%) cases.

CONCLUSION

Retroperitoneoscopic en bloc RPLND permits complete and radical removal of the lymphatic tissue contained in the RPLND template. Our en bloc technique is a safe and feasible procedure with comparable blood loss and complication rates.

Oncological outcomes of neoadjuvant chemotherapy in patients with locally advanced upper tract urothelial carcinoma: a multicenter study

Objective

The clinical impact of neoadjuvant chemotherapy (NAC) on oncological outcomes in patients with locally advanced upper tract urothelial carcinoma (UTUC) remains unclear. We investigated the oncological outcomes of platinum-based NAC for locally advanced UTUC.

Results

Of 234 patients, 101 received NAC (NAC group) and 133 did not (Control [Ctrl] group). The regimens in the NAC group included gemcitabine and carboplatin (75%), and gemcitabine and cisplatin (21%). Pathological downstagings of the primary tumor and lymphovascular invasion were significantly improved in the NAC than in the Ctrl groups. NAC for locally advanced UTUC significantly prolonged recurrence-free and cancer-specific survival. Multivariate Cox regression analysis using an inverse probability of treatment weighted (IPTW) method showed that NAC was selected as an independent predictor for prolonged recurrence-free and cancer-specific survival. However, the influence of NAC on overall survival was not statistically significant.

Materials and Methods

A total of 426 patients who underwent radical nephroureterectomy at five medical centers between January 1995 and April 2017 were examined retrospectively. Of the 426 patients, 234 were treated for a high-risk disease (stages cT3–4 or locally advanced [cN+] disease) with or without NAC. NAC regimens were selected based on eligibility of cisplatin. We retrospectively evaluated post-therapy pathological downstaging, lymphovascular invasion, and prognosis stratified by NAC use. Multivariate Cox regression analysis was performed for independent factors for prognosis.

Conclusions

Platinum-based NAC for locally advanced UTUC potentially improves oncological outcomes. Further prospective studies are needed to clarify the clinical benefit of NAC for locally advanced UTUC.

Preoperative chronic kidney disease predicts poor oncological outcomes after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma

Objective

To evaluate the impact of preoperative chronic kidney disease (CKD) on oncological outcomes in patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy.

Methods

A total of 426 patients who underwent radical nephroureterectomy at five medical centers between February 1995 and February 2017 were retrospectively examined. Oncological outcomes, including intravesical recurrence-free, visceral recurrence-free, cancer-specific, and overall survival rates (intravesical RFS, visceral RFS, CSS, and OS, respectively) stratified by preoperative CKD status (CKD vs. non-CKD) were investigated. Cox proportional hazards regression analysis was performed using inverse probability of treatment weighting (IPTW) to evaluate the impact of preoperative CKD on prognosis and a prognostic factor-based risk stratification nomogram was developed.

Results

Of the 426 patients, 250 (59%) were diagnosed with CKD before radical nephroureterectomy. Before the background adjustment, intravesical RFS, visceral RFS, CSS, and OS after radical nephroureterectomy were significantly shorter in the CKD group than in the non-CKD group. Background-adjusted IPTW analysis demonstrated that preoperative CKD was significantly associated with poor visceral RFS, CSS, and OS after radical nephroureterectomy. Intravesical RFS was not significantly associated with preoperative CKD. The nomogram for predicting 5-year visceral RFS and CSS probability demonstrated a significant correlation with actual visceral RFS and CSS (c-index = 0.85 and 0.83, respectively).

Conclusions

Upper tract urothelial carcinoma patients with preoperative CKD had a significantly lower survival probability than those without CKD.

Laparoscopic nephroureterectomy for upper tract urothelial carcinoma - Update

Upper urinary tract urothelial carcinomas (UTUCs) are uncommon and account for only 5%-10% of urothelial carcinomas. Pyelocaliceal tumors are about twice as common as ureteral tumors. Sixty percent of UTUCs are invasive at diagnosis. Radical nephroureterectomy, including the excision of the distal ureter and bladder cuff is standard of care for treatment of localized UTUCs, because of the high potential for recurrence, multifocality, and progression. Since first laparoscopic nephroureterectomy (LNU) was introduced by Clayman et al. in 1991 and improvement of laparoscopic technique and equipment, LNU has been reported to be equivalent to conventional open method. We reviewed the current literature of patients with UTUCs treated by LNU focusing on technical aspects, peri-operative and oncological outcomes. Laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome for treatment of UTUCs. Indications tend to increase as operator skills increase. Indications for laparoscopic or open nephroureterectomy are in principle the same. The basic requirement for laparoscopic surgery in UTUCs is to achieve benefits of minimal invasive surgery and maintain oncologic principles.

Long-term oncologic outcomes of laparoscopic nephroureterectomy versus open nephroureterectomy for upper tract urothelial carcinoma: a systematic review and meta-analysis

Background. Several factors have been validated as predictors of disease recurrence in upper tract urothelial carcinoma. However, the oncological outcomes between different surgical approaches (open nephroureterectomy versus laparoscopic nephroureterectomy, ONU vs LNU) remain controversial. Therefore, we performed a meta-analysis to evaluate the oncological outcomes associated with different surgical approaches.

Methods. We conducted an electronic search of the PubMed, Embase, ISI Web of Knowledge and Cochrane Library electronic databases through November 2015, screened the retrieved references, collected and evaluated the relevant information. We extracted and synthesized the corresponding hazard ratios (HRs) and 95% confidence intervals (95% CI) using Stata 13.

Results. Twenty-one observational studies were eligible for inclusion in the meta-analysis. The results of the meta-analysis showed no differences in the intravesical recurrence-free survival (IRFS), unspecified recurrence-free survival (UnRFS) and overall survival (OS) between LNUandONU. However, improvements in the extravesical recurrence free survival (ExRFS) and cancer specific survival (CSS) were observed inLNU. The pooled hazard ratios were 1.05 (95% CI [0.92–1.18]) for IRFS, 0.80 (95% CI [0.64–0.96]) for ExRFS, 1.10 (95% CI [0.93–1.28]) for UnRFS, 0.91 (95% CI [0.66–1.17]) for OS and 0.79 (95% CI [0.68–0.91]) for CSS.

Conclusion. Based on current evidence, LNU could provide equivalent prognostic effects for upper tract urothelial carcinoma, and had better oncological control of ExRFS and CSS compared to ONU. However, considering all eligible studies with the intrinsic bias of retrospective study design, the results should be interpreted with caution. Prospective randomized trials are needed to verify these results.