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

Prognostic effects of different nephroureterectomy techniques for upper urinary tract urothelial carcinoma: a network meta-analysis

BACKGROUND

Upper urinary tract urothelial carcinoma (UTUC) is an aggressive malignant tumor, with surgical intervention as the primary treatment. This study evaluates the prognostic effects of laparoscopic radical nephroureterectomy (LNU), open radical nephroureterectomy (ONU), robot-assisted laparoscopic radical nephroureterectomy (Robotic LNU), and hand-assisted laparoscopic radical nephroureterectomy (Hand LNU) in the treatment of UTUC through a network meta-analysis.

METHODS

A systematic search of the PubMed, EMBASE, Cochrane, and Web of Science databases was conducted for randomized controlled trials meeting the criteria from database inception until April 2024. Bayesian network meta-analysis was performed to compare the effects of each surgical method on overall survival (OS), cancer-specific survival (CSS), and overall recurrence rate (ORE).

RESULTS

Seventeen randomized controlled trials were included in this network meta-analysis. The results indicated that LNU significantly improved CSS compared to ONU [HR = 0.81, 95%CI= (0.7, 0.93)], while there were no significant differences between Hand LNU and Robotic LNU compared to ONU. Among minimally invasive surgeries, Hand LNU significantly shortened CSS compared to LNU [HR = 1.49, 95%CI=(1.1, 2.03)]. Regarding ORE, no significant differences were found between LNU, Hand LNU, and Robotic LNU compared to ONU, although LNU had a higher recurrence rate than Robotic LNU [HR = 1.705, 95%CI=(1.007, 3.001)]. For OS, both LNU [HR = 0.84, 95%CI=(0.75, 0.94)] and Robotic LNU [HR = 0.81, 95%CI=(0.68, 0.96)] were significantly better than ONU, whereas Hand LNU significantly shortened OS compared to LNU and Robotic LNU. There were no significant differences in progression-free survival (PFS) between LNU and ONU. The cumulative efficacy ranking indicated that Robotic LNU ranked highest for ORE and OS, while LNU ranked first for CSS.

CONCLUSION

Robotic LNU demonstrates advantages in prolonging OS and reducing recurrence rates, while LNU excels in improving CSS. Although Hand LNU shows suboptimal effects in some comparisons, it remains valuable, and surgical choices should be based on individualized needs.

The surgical technique and efficacy of a novel pure retroperitoneoscopic extravesical bladder cuff excision without intraoperative repositioning for upper tract urothelial carcinoma

To evaluate the feasibility, effectiveness and therapeutic outcomes of a novel pure retroperitoneoscopic extravesical bladder cuff excision (PREBE) in patients with upper tract urothelial carcinoma (UTUC), a retrospectively comparative study between PREBE and traditional laparoscopic nephroureterectomy (TLNU) was done in a single center. We retrospectively evaluated 72 patients diagnosed with UTUC at our hospital from January 2022 to January 2024. The patients who underwent TLNU (n = 35) and PREBE (n = 37) were consecutively enrolled. The kidney and bladder cuff were retroperitoneoscopically dissected and the bladder was repaired with needle sutures under retroperitoneoscopic in the PREBE group. Demographic, perioperative, and follow-up data were collected and compared between the two groups. Both procedures were performed effectively in 72 patients without converting to open surgery. The PREBE group exhibited shorter mean operative time (P < 0.01), less mean estimated blood loss (EBL) (P < 0.01), shorter median drainage tube removal time, shorter median first postoperative defecation (FPD) time (P < 0.01) and shorter median postoperative hospital stay (P < 0.01). However, there was no statistical difference in postoperative pathological results or in the incidence of intravesical recurrence between the two groups. The mean follow-up time was 13.8 months for the PREBE group and 14.4 months for the TLNU group. The PREBE is a safe and effective treatment for patients with UTUC, avoiding intraoperative patient repositioning while offering better perioperative outcomes to those of traditional techniques.

Differential effect of surgical technique on intravesical recurrence after radical nephroureterectomy in patients with upper tract urothelial cancer: a systematic review and Meta-analysis

CONTEXT

Radical nephroureterectomy (RNU) with bladder cuff resection is the standard treatment in patients with high-risk upper tract urothelial cancer (UTUC). However, it is unclear which specific surgical technique may lead to improve oncological outcomes in term of intravesical recurrence (IVR) in patients with UTUC.

OBJECTIVE

To evaluate the efficacy of surgical techniques and approaches of RNU in reducing IVR in UTUC patients.

EVIDENCE ACQUISITION

Three databases were queried in January 2024 for studies analyzing UTUC patients who underwent RNU. The primary outcome of interest was the rate of IVR among various types of surgical techniques and approaches of RNU.

EVIDENCE SYNTHESIS

Thirty-one studies, comprising 1 randomized controlled trial and 1 prospective study, were included for a systematic review and meta-analysis. The rate of IVR was significantly lower in RNU patients who had an early ligation (EL) of the ureter compared to those who did not (HR: 0.64, 95% CI: 0.44-0.94, p = 0.02). Laparoscopic RNU significantly increased the IVR compared to open RNU (HR: 1.28, 95% CI: 1.06-1.54, p < 0.001). Intravesical bladder cuff removal significantly reduced the IVR compared to both extravesical and transurethral bladder cuff removal (HR: 0.65, 95% CI: 0.51-0.83, p = 0.02 and HR: 1.64, 95% CI: 1.15-2.34, p = 0.006, respectively).

CONCLUSIONS

EL of the affected upper tract system, ureteral management, open RNU, and intravesical bladder cuff removal seem to yield the lowest IVR rate in patients with UTUC. Well-designed prospective studies are needed to conclusively elucidate the optimal surgical technique in the setting of single post-operative intravesical chemotherapy.

Impact of nephroureterectomy on postoperative renal function in upper tract urothelial carcinoma: A multicenter retrospective study

OBJECTIVE

To assess the impact of radical nephroureterectomy on postoperative renal function in patients with upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively evaluated 645 patients with UTUC treated with radical nephroureterectomy between January 2000 and May 2022. The primary outcome was the rate of postoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 . Secondary outcomes included the rate of eGFR decline, identification of factors related to eGFR decline, and the impact of comorbidities (diabetes or cardiovascular disease) on postoperative eGFR at 1 year.

RESULTS

The median preoperative and postoperative eGFR levels were 55.6 and 43.3 mL/min/1.73 m2 , respectively. The rate of patients with preoperative and postoperative eGFR ≥60 mL/min/1.73 m2 was 40.9% and 9.0%, respectively. The median decline in eGFR after surgery was 25.1%. The presence of preoperative unilateral hydronephrosis and eGFR <60 mL/min/1.73 m2 was significantly associated with a low decline of postoperative eGFR and poor survival. The impact of the presence of comorbidities on postoperative eGFR at 1 year was significant (p < 0.001).

CONCLUSION

Impaired renal function is prevalent in patients with UTUC. The rate of patients with postoperative eGFR ≥60 mL/min/1.73 m2 was 9.0%. The presence of preoperative renal impairment was significantly related to a low decline in postoperative eGFR and poor survival. The presence of comorbidities had a significant effect on eGFR decline 1 year after radical nephroureterectomy.

Comparison of Perioperative Outcomes and Complications of Laparoscopic and Robotic Nephroureterectomy Approaches in Patients with Upper-Tract Urothelial Carcinoma

BACKGROUND

For medical institutions without robotic equipment, it remains uncertain whether laparoscopic radical nephroureterectomy (LNU) can achieve results similar to those of robotic surgery for the treatment of upper tract urothelial carcinoma (UTUC). This meta-analysis aimed to compare the efficacy and safety of robot-assisted radical nephroureterectomy (RANU) with that of LNU using a large sample size of patients.

METHODS

A systematic meta-analysis was performed using data (available to May 2022) acquired from multiple scientific databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines, according to the protocols registered with PROSPERO (CRD42021264046), were followed to perform this cumulative analysis.

RESULTS

Nine high-quality studies were included in this analysis, considering factors such as operative time (OT), estimated blood loss (EBL), length of hospital stay (LOS), positive surgical margins (PSM), and complications. Statistical indicators revealed no significant differences between the RANU and LNU groups in terms of OT (weighted mean difference [WMD] 29.41, 95% confidence interval [CI] -1.10 to 59.92; p = 0.22), EBL (WMD -55.30, 95% CI -171.14 to 60.54; p = 0.13), LOS (WMD -0.39, 95% CI -1.03 to 0.25; p = 0.12), PSM (odds ratio [OR] 1.22, 95% CI 0.44-3.36; p = 0.17], or complications (OR 0.91, 95% CI 0.49-1.69; p = 0.13).

CONCLUSION

The meta-analysis showed that the perioperative and safety indicators of both RANU and LNU were similar and both showed favorable outcomes in UTUC treatment. However, some uncertainties remain in the implementation and selection of lymph nodes for dissection.

Lymph Node Dissection During Radical Nephro-Ureterectomy for Upper Tract Urothelial Carcinoma: A Review

Although lymphonodal dissection is well-accepted for muscle-invasive bladder cancer management, its role is still debated during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). The aim of this study was to summarize the current knowledge concerning the indication, anatomical template, prognostic, and therapeutic roles of lymph node dissection (LND) performed at the time of RNU. Quality control markers, such as the number of lymph nodes (LN) removed, lymph node density, and safety of the different surgical approaches, were assessed. We performed a narrative review using the PubMed and ClinicalTrials.gov databases. We identified and analyzed articles based on the practice and the role of lymph node dissection for non-metastatic UTUC. There are no clear guidelines regarding the indication of LND for UTUC, but aggressive tumors may beneficiate from lymphadenectomy since lymph node invasion is a clear independent poor prognostic factor, allowing for adjuvant treatments. It seems that an extended lymphadenectomy may provide therapeutic advantages as a higher number of nodes removed may be related to the removal of undetected LNs micrometastases and a subsequent improvement in recurrence rate and cancer-specific survival. Clear anatomical templates are thus needed based on the location and the laterality of the primary tumor.

A retrospective multicenter comparison of conditional cancer-specific survival between laparoscopic and open radical nephroureterectomy in locally advanced upper tract urothelial carcinoma

BACKGROUND

Upper urinary tract urothelial carcinomas are relatively rare and have a cancer-specific survival rate of 20%-30%. The current gold standard treatment for nonmetastatic high-grade urinary tract urothelial carcinoma is radical nephroureterectomy with bladder cuff resection.

OBJECTIVE

This study aimed to compare conditional cancer-specific survival between open radical nephroureterectomy and laparoscopic radical nephroureterectomy in patients with nonmetastatic stage pT3-4 or TxN(+) locally advanced urinary tract urothelial carcinoma from five tertiary centers.

METHODS

The medical records of 723 patients were retrospectively reviewed. The patients had locally advanced and nodal staged tumors and had undergone open radical nephroureterectomy (n = 388) or laparoscopic radical nephroureterectomy (n = 260) at five tertiary Korean institutions from January 2000 and December 2012. To control for heterogenic baseline differences between the two modalities, propensity score matching and subgroup analysis were conducted. Conditional survival analysis was also conducted to determine survival outcome and to overcome differences in follow-up duration between the groups.

RESULTS

During the median 50.8-month follow up, 255 deaths occurred. In univariate analysis, significant factors affecting cancer-specific survival (e.g., age, history of bladder cancer, American Society of Anesthesiologists score, pathological N stage, and presence of lymphovascular invasion and carcinoma in situ) differed in each subsequent year. The cancer-specific survival between patients treated with open radical nephroureterectomy and laparoscopic radical nephroureterectomy was not different between patients with and without a history of bladder cancer. After adjusting baseline differences between the two groups by using propensity score matching, both groups still had no significant differences in cancer-specific survival.

CONCLUSION

The two surgical modalities showed no significant differences in the 5-year cancer-specific survival in patients with locally advanced urinary tract urothelial carcinoma.

Prognostic impact of eligibility for adjuvant immunotherapy in locally advanced urothelial cancer

Objective

To evaluate the effect of postoperative pathological findings related to the eligibility of adjuvant immunotherapy on oncologic outcomes in patients with localized and locally advanced muscle‐invasive bladder carcinoma (MIBC) and upper tract urothelial carcinoma (UTUC).

Patients and methods

We retrospectively evaluated 1082 patients treated with radical cystectomy (n = 597) and nephroureterectomy (n = 485) between January 2000 and April 2021. Patients were divided into two groups: pT3‐4 or pN+ without neoadjuvant chemotherapy and ypT2‐4 or pN+ treated with neoadjuvant chemotherapy (trial‐eligible group) or others (trial‐ineligible group). The primary outcome was the effect of trial eligibility for adjuvant immunotherapy on disease‐free survival (DFS) and overall survival (OS). Secondary outcomes included the additional effect of lymphovascular invasion (LVI) status to the clinical trial criteria on prognosis and a risk model development.

Results

The median ages of the patients were 69 and 72 years in the MIBC and UTUC groups, respectively. Fifty‐two percent of patients met the trial inclusion criteria. Trial eligibility was significantly associated with poor DFS and OS among patients with MIBC and UTUC. LVI‐positive status was significantly associated with poor prognosis among patients in the trial‐eligible group. A very high risk (LVI+ or pN+ among the pT3‐4 or ypT2‐4) was significantly associated with poor prognosis.

Conclusion

A total of 52% of patients were eligible for adjuvant immunotherapy. Trial eligibility was significantly associated with a poor prognosis. LVI+ and pN+ may play a key role in candidate selection for adjuvant immunotherapy.

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.

Oncological outcomes of laparoscopic versus open nephroureterectomy for the treatment of upper tract urothelial carcinoma: an updated meta-analysis

Background

During the past two decades, laparoscopic radical nephroureterectomy (LRNU) has been proposed as an alternative technique to open radical nephroureterectomy (ORNU) and has become increasingly accepted for the treatment of patients with upper tract urothelial carcinoma (UTUC). Nevertheless, the oncologic efficacy of LRNU remains controversial, especially for the treatment of locally advanced (T3/T4 and/or N+) UTUC. In this meta-analysis, we aimed to cumulatively compare the oncological outcomes of LRNU versus ORNU.

Materials and methods

The present meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A search was conducted of three electronic databases, namely, Medline, Embase, and Cochrane Library. Outcome measurements of cancer-specific survival (CSS), overall survival (OS), intravesical recurrence-free survival (IVRFS), and recurrence-free survival (RFS), including hazard ratios (HRs) and 95% confidence intervals (CIs), were extracted and pooled.

Results

Eighteen articles published from 2007 to 2020 were included in the final quantitative analysis. One study was a randomized controlled trial (RCT), and the remaining articles had a retrospective design. Among a total of 10,730 participants in the selected papers, 5959 (55.5%) and 4771 (44.5%) underwent ORNU and LRNU, respectively. The results of pooled analyses revealed no significant differences in CSS (HR 0.84, 95% CI 0.60–1.19, p = 0.33), OS (HR 0.84, 95% CI 0.62–1.13, p = 0.25), IVRFS (HR 1.08, 95% CI 0.85–1.39, p = 0.52), and RFS (HR 1.09, 95% CI 0.94–1.25, p = 0.26) between LRNU and ORNU groups. Furthermore, the results of subgroup analyses for pT3/T4 and pTany N+ populations did not confirm any statistically significant differences between LRNU and ORNU in terms of any survival parameter.

Conclusions

Our present meta-analysis of current evidence suggests that LRNU and ORNU have comparable oncological outcomes in patients with UTUC, even in those with locally advanced disease. Further multicenter RCTs with large sample sizes and uniform data regarding specific surgical procedures, such as bladder cuff excision, are required to establish definitive conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02236-z.

Trends in the use of neoadjuvant chemotherapy and oncological outcomes for high‐risk upper tract urothelial carcinoma: a multicentre retrospective study

Objective

Patients and Methods

Results

Conclusions

Influence of pretreatment quality of life on prognosis in patients with urothelial carcinoma

BACKGROUND

We investigated the association between the pretreatment quality of life (QOL) and overall survival (OS) in patients with urothelial carcinoma (UC), as the influence of pretreatment QOL on prognosis remains unclear in patients with localized and metastatic UC.

METHODS

Between June 2013 and May 2019, we retrospectively investigated 205 patients with UC who received radical cystectomy or nephroureterectomy for non-metastatic UC (M0 group) or systemic chemotherapy for metastatic UC (M1 group). Patients answered the European Organization for the Research and Treatment of Cancer Quality-of-Life Questionnaire C30 (QLQ-C30) before the treatments. Patients were stratified into two groups: QOL high and low according to the optimal cutoff scores which were defined by receiver operating characteristic curve. Inverse probability of treatment weighting (IPTW)-adjusted multivariate Cox regression analyses were performed to investigate the clinical implication of pretreatment QOL score on OS in patients with UC.

RESULTS

The number of patients in the M0 and M1 groups was 125 and 80, respectively. Optimal cutoff values in global, fatigue, pain, appetite loss, physical, and role scores were < 50, > 33, > 33, > 16, < 80, and < 67, respectively. IPTW-adjusted multivariate Cox regression analyses revealed that appetite loss score indicated a significantly poorer OS in the M1 group. No significant association of QOL with OS was observed in the M0 group.

CONCLUSION

Pretreatment QOL of appetite loss may predict poor prognosis of patients with metastatic UC.

Lymphadenectomy for Upper Tract Urothelial Carcinoma: A Systematic Review

Background: The role of lymphonodal dissection during surgery for a tumor of the urinary tract remains controversial. Objective: To analyze anatomical bases of lymphonodal dissection in tumors of the upper urinary tract and analyze its impact on survival, recurrence, and staging. Acquisition of data: A web-based search for scientific articles using Medline/Pubmed was carried out to identify and analyze articles on the practice and the role of lymphonodal dissection in this indication. Data Synthesis: The lymphatic drainage of the upper urinary tract has rarely been studied and is poorly understood. The lymphonodal metastatic extension is the most common extension in upper urinary tract urothelial carcinoma. Lymphnode invasion is a clear independent poor prognostic factor. Therefore, it seems legitimate to offer an extended lymphonodal dissection to patients undergoing surgery to cure these tumors. When lymphnodes dissection respects clear anatomical principles based on the location of the primary tumor and its extension, it improves both survival and recurrence rates. This result could be secondary to the treatment of subclinical metastatic disease. Conclusion: An extended lymphadenectomy during surgery for upper urinary tract urothelial carcinoma following strict anatomical pattern improves staging with a highly probable therapeutic benefit.

Laparoscopy versus Open Nephroureterectomy in Prognostic Outcome of Patients with Advanced Upper Tract Urothelial Cancer: A Retrospective, Multicenter, Propensity-Score Matching Analysis

PURPOSE

The purpose of this study was to compare oncologic outcomes between open nephroureterectomy (ONU) and laparoscopic nephroureterectomy (LNU) in patients with upper tract urothelial carcinoma.

MATERIALS AND METHODS

The medical records of consecutive ONU and LNU cases from five tertiary institutions were retrospectively analyzed between 2000 and 2012. The propensity-score matching methodology was used to compare the two surgical approaches in terms of age, body mass index, American Society of Anesthesiologists score, tumor location, grade, pathologic T and N categories, the presence of lymphovascular invasion, and follow-up duration. The Kaplan-Meier with log-rank tests and clustered Cox regression were used to compare the estimated rates of survival for each surgical approach and to investigate the effect of the surgical approach on each prognostic outcome.

RESULTS

Six hundred thirty-eight propensity-score matching pairs (n=1,276) were compared; LNU was significantly better than ONU in all types of survival, including intravesical recurrencefree survival (IVRFS), disease-free survival, overall survival (OS), and cancer-specific survival (CSS) (p < 0.05). The 3-year OS and CSS rates were significantly higher with LNU than with ONU (p < 0.05). Compared with ONU, LNU had significantly better 3-year OS and CSS rates (82.9% and 86.2% vs. 78.3% and 81.8%); there were no differences at 5 years. In subgroup analysis of the early-staged group, advanced-stage group, lymph node-positive group, and lymph node-negative group, the two approaches did not significantly affect prognostic outcomes, except LNU improved the IVRFS in the lymph node-negative or no history of previous bladder cancer group.

CONCLUSION

LNU had a significantly better prognostic outcome than ONU after propensity-score matching.

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: results from three high-volume robotic surgery institutions

Robot-Assisted NephroUreterectomy (RANU) represents a minimally invasive alternative to open NephroUreterectomy (NU) for management of Upper Tract Urothelial Carcinoma (UTUC) but its oncologic safety is still controversial. The objective of this study was to investigate the peri-operative, pathologic and oncologic outcomes of RANU for UTUC. From 2008 to 2017, 78 patients diagnosed with UTUC and elected for RANU at 3 high-volume robotic surgery centres were retrospectively assessed. Surgery was performed using da Vinci Si^® and Xi^® systems. RANU was done adhering to oncological principles as in open surgery. The outcomes of the study were: (1) peri-operative morbidity, namely intra- and post-operative complications, blood loss, length of hospital stay and operative time; (2) oncologic outcomes, namely overall survival (OS) and recurrence-free survival (RFS). Peri-operative overall complication rate was 24.4% and high-grade complication rate was 2.6%. Median blood loss, length of hospital stay and operative time were 124 ml, 4 days and 167 min. Lymphadenectomy was performed in 31 (41%) patients. Lymph-node involvement was present in 9 (29%) patients. At median follow-up of 15 months, 2- and 4-year OS were 79% and 66%, respectively, and RFS was 63% and 53%. Peritoneal dissemination was recorded in 1 (1.3%) patient with pT4N2R1 UTUC. Our study is limited by the relatively small cohort of patients and its retrospective character. RANU as minimally invasive treatment for patients with UTUC is safe and feasible. Post-operative morbidity is low and major complications are rare. Oncologic outcomes are acceptable and no evidence of increased risk of peritoneal dissemination is recorded. Long-term data are needed. RANU should be regarded as an alternative to open surgery for UTUC that can offer good peri-operative and oncologic results.

Comparison of oncological and perioperative outcomes of open, laparoscopic, and robotic nephroureterectomy approaches in patients with non-metastatic upper-tract urothelial carcinoma

BACKGROUND

To compare the oncological and perioperative outcomes of different nephroureterectomy approaches in patients with non-metastatic upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed the data of 422 patients who underwent open, laparoscopic, or robotic nephroureterectomy for non-metastatic UTUC. Perioperative and postoperative survival outcomes were compared using Kaplan-Meier analyses and Cox-proportional hazard models.

RESULTS

Of the patients, 161, 137, and 124 were treated with an open, laparoscopic, and robotic approach, respectively. Laparoscopic and robotic approaches involved significantly less blood loss (p = 0.001), shorter hospital stay (p < 0.001), and longer operation time (p < 0.001) compared with the open approach. There were no significant differences in intraoperative complications (open, 8.1%; laparoscopic, 5.1%; robotic, 7.3%; p = 0.363) or early postoperative complications (open, 14.9%; laparoscopic, 14.6%; robotic, 13.7%; p = 0.880). The laparoscopic and robotic groups showed significantly less postoperative analgesic use (p = 0.015). The robotic group showed significantly longer progression-free, cancer-specific, and overall survivals than the open approach group on univariate Kaplan-Meier analysis, but surgery type was not significantly associated with survival outcomes per multivariate Cox proportional tests (all p-values > 0.05).

CONCLUSION

The laparoscopic and robotic approaches yielded better perioperative outcomes, such as less intraoperative bleeding, shorter hospital stays, less analgesic usage, and non-inferior oncological outcomes, compared with the open approach. Further prospective studies are needed to compare these surgical techniques.

Postoperative weight loss followed by radical cystectomy predicts poor prognosis in patients with muscle-invasive bladder cancer

We aimed to investigate the impact of postoperative weight loss following radical cystectomy (RC) on patients' prognoses. RC and urinary diversion were performed in 512 consecutive patients with muscle-invasive bladder cancer at our hospitals between May 1996 and July 2018. Demographic clinical information, pre- and postoperative serum albumin, hemoglobin, and weight were evaluated retrospectively at 1 month. We also evaluated the association of weight loss with complications and overall survival (OS) as estimated using the Kaplan-Meier method and compared using the log-rank test. Risk factors for poor OS were determined by Inverse Probability of Treatment Weighted (IPTW)-adjusted Cox regression analysis. In 385 patients who met the study search criteria, median postoperative weight loss from baseline at 1 week and 1 month was 1.1 (- 1.8%) and 3.2 (- 5.4%) kg, respectively. Patients with significant weight loss (defined as ≥ 7.5% at 1 month) had higher-grade complications within 1 month and had significantly shorter OS than those with weight loss of < 7.5%. Type of urinary diversion, loss of serum albumin, and loss of hemoglobin were not significantly associated with weight loss. IPTW-adjusted Cox regression analysis showed that such significant weight loss was an independent risk factor for poor OS. Weight loss followed by radical cystectomy was significantly associated with poor prognosis in patients with muscle-invasive bladder cancer.

Asymptomatic recurrence detection and cost-effectiveness in urothelial carcinoma

For the management of muscle-invasive bladder cancer or upper tract urothelial carcinoma, the set guidelines recommend regular surveillance after radical cystectomy or radical nephroureterectomy. However, the prognostic benefit of regular oncological surveillance remains controversial in the absence of prospective studies although several retrospective studies with relatively large sample sizes have demonstrated the association between asymptomatic recurrence and better oncological outcomes. Seven out of eight studies reported that patients diagnosed with symptomatic recurrence showed significantly poorer prognosis in comparison to those diagnosed with asymptomatic recurrence. However, potential lead-time and length-time biases prevent the determination of any benefit of regular surveillance. In addition, an optimal surveillance protocol has yet to be established because conventional pathology-based protocols cannot identify the heterogenetic tumor biology of urothelial carcinoma, such as rapid- or slow-growing form of the disease. Several studies suggest that conventional pathology-based surveillance resulted in reduced cost-effectiveness. Recurrence risk-score stratified surveillance protocol including clinical and pathological factors may improve cost-effectiveness. The establishment of optimal risk stratification and surveillance strategies are required to improve the efficacy of regular oncological surveillance. Well-planned prospective studies are necessary to address the prognostic benefit of regular oncological surveillance and shared decision making.

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.

The Impact of Preoperative Severe Renal Insufficiency on Poor Postsurgical Oncological Prognosis in Patients with Urothelial Carcinoma

BACKGROUND

The impact of preoperative renal impairment severity on prognosis in urothelial carcinoma remains unelucidated.

OBJECTIVE

To evaluate the impact of severe preoperative renal insufficiency on oncological outcomes in patients with urothelial carcinoma who underwent radical cystectomy or nephroureterectomy.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1066 patients with urothelial carcinoma who underwent radical cystectomy or nephroureterectomy at six medical centres from February 1995 to November 2017 were retrospectively examined.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Oncological outcomes, stratified using preoperative estimated glomerular filtration rate (eGFR≥60, 45≤eGFR<60, and eGFR<45ml/min/1.73m²), were investigated. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analysis was performed to evaluate the impact of preoperative eGFR on prognosis.

RESULTS AND LIMITATIONS

Of 610 patients with muscle-invasive bladder cancer (MIBC), 80 (13%) had severe renal insufficiency (eGFR<45ml/min/1.73m²). Of 456 patients with upper tract urothelial carcinoma (UTUC), 101 (22%) had severe renal insufficiency. Significant differences were noted in background and prognosis among the patients with preoperative eGFR≥60, 45≤eGFR<60, and eGFR<45ml/min/1.73m². Findings of IPTW-adjusted Cox regression analysis demonstrated that preoperative eGFR<45ml/min/1.73m² was significantly associated with poor postsurgical recurrence-free, cancer-specific and overall survival rates in patients with either MIBC or UTUC.

CONCLUSIONS

Patients with urothelial carcinoma with preoperative eGFR<45ml/min/1.73m² had a significantly lower survival probability than those without.

PATIENT SUMMARY

In this report, we found that preoperative severe renal insufficiency (estimated glomerular filtration rate<45ml/min/1.73m²) had higher risk for relapse and lower survival probability. Close attention is necessary when urothelial carcinoma patients have severe renal insufficiency before radical cystectomy or nephroureterectomy.