Robotic Nephroureterectomy

Analysis of progression after elective distal ureterectomy and effects of salvage radical nephroureterectomy in patients with distal ureteral urothelial carcinoma

We compared the progression patterns after radical nephroureterectomy (RNU) and elective distal ureterectomy (DU) in patients with urothelial carcinoma of the distal ureter. Between Jan 2011 and Dec 2020, 127 patients who underwent RNU and 46 who underwent elective DU for distal ureteral cancer were enrolled in this study. The patterns of progression and upper tract recurrence were compared between the two groups. Progression was defined as a local recurrence and/or distant metastasis after surgery. Upper tract recurrence and subsequent treatment in patients with DU were analyzed. Progression occurred in 35 (27.6%) and 10 (21.7%) patients in the RNU and DU groups, respectively. The progression pattern was not significantly different (p = 0.441), and the most common progression site was the lymph nodes in both groups. Multivariate logistic regression analysis revealed that pT2 stage, concomitant lymphovascular invasion, and nodal stage were significant predictors of disease progression. Upper tract recurrence was observed in nine (19.6%) patients with DU, and six (66.7%) patients had a prior history of bladder tumor. All patients with upper tract recurrence after DU were managed with salvage RNU. Elective DU with or without salvage treatment was not a risk factor for disease progression (p = 0.736), overall survival (p = 0.457), cancer-specific survival (p = 0.169), or intravesical recurrence-free survival (p = 0.921). In terms of progression patterns and oncological outcomes, there was no difference between patients who underwent RNU and elective DU with/without salvage treatment. Elective DU should be considered as a therapeutic option for distal ureter tumor.

Robot-assisted vs. laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis based on comparative studies

Background

Robot-assisted nephroureterectomy (RANU) and laparoscopic nephroureterectomy (LNU) are two minimally invasive surgical management for upper urinary tract urothelial carcinomas (UTUC). Though more high-tech, it remains largely unclear whether RANU provides additional benefits over LNU. We aimed to quantitatively compare the perioperative and oncologic outcomes between RANU and LNU.

Methods

The systematic review was performed based on a registered protocol (registration number CRD42022319086). We searched through PubMed, EMBASE and Cochrane databases, as well as conference proceedings and references of review articles (May 2022) for comparative studies reporting perioperative and oncologic outcomes independently in RANU and LNU groups. Selection of studies and data extraction were performed independently by two researchers. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. Results of random-effects meta-analyses were presented as mean differences (MD) or Odds ratio (OR), as appropriate. Subgroup and univariate meta-regression analyses were performed to identify interstudy heterogeneities.

Results

The review included 8470 patients undergoing RANU and 19872 patients undergoing LNU from 12 comparative original studies. RANU was associated with fewer overall complications (OR=0.71, 95%CI: 0.62 to 0.81), longer operative time (MD=27.70, 95%CI: 0.83 to 54.60) and shorter length of stay (MD=-0.53, 95%CI: -0.98 to -0.07) compared to LNU. In addition, patients receiving RANU were more likely to have lymph node dissected (OR=2.61, 95%CI: 1.86 to 3.65). Recurrence and survival outcomes did not differ between two surgical procedures. Sample size, types of LNU and world region were major sources of heterogeneity.

Conclusion

For UTUC patients, RANU offers fewer complications and shorter hospitalization. However, RANU requires longer operative time and shares similar oncologic outcomes compared to LNU. Further randomized designed studies are warranted.

Systematic Review Registration

www.crd.york.ac.uk/prospero/, identifier CRD42022319086.

Robotic Radical Nephroureterectomy with Bladder Cuff Excision for Upper Tract Urothelial Carcinoma: A Trend Analysis of Utilization and a Comparative Study

Purpose: To compare the perioperative outcomes and oncological results of open, laparoscopic, and robotic radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC) and to analyze trends in the utilization of RNU. Methods: From 2017 to 2020, the records of 61, 185, and 119 patients who underwent open, laparoscopic, and robotic RNU, respectively, were reviewed. Results: Baseline characteristics were not significantly different among the three groups. Robotic RNU has recently started to increase from 9% in 2017 to 67% in 2021. Operation time, blood loss, length of hospital stay, and 90-day complications were not different between the three groups. The three-year overall survival (OS) rates for open, laparoscopic, and robotic RNU were 91.8%, 90.4%, and 92.1%, respectively (p > 0.05). No differences in the progression-free survival (PFS), cancer-specific survival (CSS), and OS were observed according to the surgical approach in the Kaplan−Meier survival analysis. Multivariate analysis showed that surgical approach was not an independent predictor of PFS, CSS, and OS. Conclusion: The use of robotic RNU in patients with UTUC has been starting to increase and replace open and laparoscopic RNU. Perioperative outcomes, 90-day complications, and oncological outcomes of robotic RNU were not inferior to those of open and laparoscopic RNU.

Robotic and 3D laparoscopic radical nephroureterectomy with en bloc specimen excision (kidney, ureter, bladder cuff excision and extended lymphadenectomy) – Case report

Introduction and importance

Case presentation

Clinical discussion

Conclusion

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Symptomatic patients presenting upper urinary tract urothelial carcinoma benefit from surgery, a minimal invasive approach being preferable.

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Nephroureterectomy with lymphnode metastasis poses surgical challenges in order to achieve negative resection margins and optimal lymphadenectomy.

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A combined 3D laparoscopic and Da Vinci X robotic surgical approach offered improved operatory time and better management of intra-pelvic disease. An optimal surgical strategy respects the surgical experience of the main surgeon combined with access to minimal invasive technology. The gentle and precise movements of the Da Vinci robot allowed an accurate dissection with en bloc specimen excision and optimal lymphadenectomy, presenting possible implications in staging and oncologic outcomes.

Robot-Assisted Surgery for Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma is a rare malignancy for which surgery provides definitive management. Open radical nephroureterectomy was the gold standard treatment, but laparoscopic and robot-assisted approaches are alternative options. Kidney-sparing approaches are feasible for carefully selected patients with ureteral cancer. This article discusses the evaluation of patients with upper tract urothelial carcinoma and definitive management using robot-assisted surgical approaches. Patients with urothelial carcinoma of the upper tract can be treated with robot-assisted nephroureterectomy, distal ureterectomy, and segmental ureterectomy.