Comparison of Oncologic Outcomes for Open and Laparoscopic Nephroureterectomy: A Multi-Institutional Analysis of 1249 Cases

doi:10.1016/j.eururo.2009.03.072

European Urology

Volume 56, Issue 1, July 2009, Pages 1-9

https://doi.org/10.1016/j.eururo.2009.03.072 Get rights and content

Abstract

Background

Data regarding the oncologic efficacy of laparoscopic nephroureterectomy (LNU) compared to open nephroureterectomy (ONU) are scarce.

Objective

We compared recurrence and cause-specific mortality rates of ONU and LNU.

Design, setting, and participants

Thirteen centers from three continents contributed data on 1249 patients with nonmetastatic upper tract urothelial carcinoma (UTUC).

Measurements

Univariable and multivariable survival models tested the effect of procedure type (ONU [n = 979] vs LNU [n = 270]) on cancer recurrence and cancer-specific mortality. Covariables consisted of institution, age, Eastern Cooperative Oncology Group (ECOG) performance status score, pT stage, pN stage, tumor grade, lymphovascular invasion, tumor location, concomitant carcinoma in situ, ureteral cuff management, previous urothelial bladder cancer, and previous endoscopic treatment.

Results and limitations

Median follow-up for censored cases was 49 mo (mean: 62). Relative to ONU, LNU patients had more favorable pathologic stages (pT0/Ta/Tis: 38.1% vs 20.8%, p < 0.001) and less lymphovascular invasion (14.8% vs 21.3%, p = 0.02) and less frequently had tumors located in the ureter (64.5 vs 71.1%, p = 0.04). In univariable recurrence and cancer-specific mortality models, ONU was associated with higher cancer recurrence and mortality rates compared to LNU (hazard ratio [HR]: 2.1 [p < 0.001] and 2.0 [p = 0.008], respectively). After adjustment for all covariates, ONU and LNU had no residual effect on cancer recurrence and mortality (p = 0.1 for both).

Conclusions

Short-term oncologic data on LNU are comparable to ONU. Since LNU was selectively performed in favorable-risk patients, we cannot state with certainty that ONU and LNU have the same oncologic efficacy in poor-risk patients. Long-term follow-up data and morbidity data are necessary before LNU can be considered as the standard of care in patients with muscle-invasive or high-grade UTUC.

Introduction

Upper tract urothelial carcinoma (UTUC) is a rare disease, accounting for 5–10% of all renal tumors and 5–6% of all urothelial tumors [1], [2]. Radical nephroureterectomy (RNU) represents the standard of care for UTUC, especially for muscle-invasive and/or high-grade disease. Open nephroureterectomy (ONU), however, may be associated with significant morbidity [1].

The role of laparoscopy has been examined in several urologic malignancies [3], [4], [5], [6]. In some pathologies, laparoscopic procedures have been shown to be equally effective as open surgery with respect to cancer control outcomes. Moreover, laparoscopic surgery may be associated with less morbidity compared to open surgery. Laparoscopic radical nephrectomy, for example, has become the standard of care at institutions with available laparoscopic expertise [5]. For other procedures such as the radical prostatectomy, the debate about the benefits and potential disadvantages of laparoscopic versus open surgery is ongoing [3], [4], [6]. In some areas of urologic oncology, the available data regarding the merits of laparoscopy are currently too immature to allow valid comparisons [7], [8]. RNU for UTUC represents one such area [9], [10], [11], [12]. Within the past decade, only four single-center reports compared cancer control outcomes of laparoscopic nephroureterectomy (LNU) with those of ONU (Table 1). The sample size of LNU cases ranged between 20 and 66, and the cumulative number of subjects was 187 [9], [10], [11], [12]. Because of the paucity of data and the single-center nature of these studies, there is a need for large, multicenter analysis of the oncologic efficacy of LNU compared to ONU. Toward this aim, we retrospectively analyzed the data from 1249 patients treated with either LNU or ONU at 13 centers from nine countries on three continents.

Section snippets

Patient selection

In this institutional review board–approved study, all participating sites provided the necessary institutional data-sharing agreements prior to initiation of the study. A total of 13 academic centers worldwide provided data. A computerized databank was generated for data transfer. After combining the data sets, reports were generated for each variable to identify data inconsistencies and other data integrity problems. Through regular communication with all sites, resolution of all identified

Results

Table 2 shows the distribution of patient characteristics. Data were stratified according to procedure type (LNU vs ONU). Relative to ONU, LNU patients were older (p = 0.01) and had worse PS scores (p = 0.01). Conversely, LNU patients had more favorable pathologic stages (p < 0.001), more frequent papillary architecture (p = 0.02), less lymphovascular invasion (p = 0.02), and less frequent primary tumor location in the ureter versus the renal pelvis (p = 0.043). There was no statistically significant

Discussion

The current standard of care for UTUC consists of ONU [1]. LNU, however, is becoming more commonly applied and is becoming established as an alternative to ONU at centers with adequate laparoscopic expertise [15], [16]. The first reports comparing LNU to ONU were published in 1993 [17], [18]. Since then, only four other reports compared long-term cancer control of LNU and ONU patients [9], [10], [11], [12]. Their individual sample sizes were limited (20–66 LNU patients). Consequently, the

Conclusions

Our data can be used as evidence for equivalent cancer control outcomes (recurrence and mortality) between LNU and ONU in patients with predominantly favorable clinical and pathologic UTUC features. Further analyses—ideally, a randomized trial—are needed to generalize these conclusions to patients with more unfavorable disease characteristics.

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Practice trends for perioperative intravesical chemotherapy in upper tract urothelial carcinoma: Low but increasing utilization during minimally invasive nephroureterectomy
2022, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
Over the past decade, minimally invasive nephroureterectomy has become a more popular surgical approach to the treatment of UTUC [33,34]. Multiple studies have demonstrated oncologic comparability between open and minimally invasive techniques, although there is some debate about the optimal surgical approach in cases of higher stage disease [8,35,36]. Our study is unable to address the effect of a minimally invasive RNU relative to open RNU on IVC administration, due to its limited inclusion criteria.
Perioperative intravesical chemotherapy (IVC) at or around the time of radical nephroureterectomy (RNU) reduces the risk of intravesical recurrence. Guidelines since 2013 have recommended its use. The objective of this study is to examine IVC utilization and determine predictors of its administration within a large international consortium.
Data was collected from 17 academic centers on patients who underwent robotic/laparoscopic RNU between 2006 and 2020. Patients who underwent concomitant radical cystectomy and cases in which IVC administration details were unknown were excluded. Univariate and multivariate analyses were utilized to determine predictors of IVC administration. A Joinpoint regression was performed to evaluate utilization by year.
Six hundred and fifty-nine patients were included. A total of 512 (78%) did not receive IVC while 147 (22%) did. Non-IVC patients were older (P < 0.001), had higher ECOG scores (P = 0.003), and had more multifocal disease (23% vs. 12%, P = 0.005). Those in the IVC group were more likely to have higher clinical T stage disease (P = 0.008), undergone laparoscopic RNU (83% vs. 68%, P < 0.001), undergone endoscopic management of the bladder cuff (20% vs. 4%, P = 0.008). Multivariable regression showed that decreased age (OR 0.940, P < 0.001), laparoscopic approach (OR 2.403, P = 0.008), and endoscopic management of the bladder cuff (OR 7.619, P < 0.001) were significant predictors favoring IVC administration. Treatment at a European center was associated with lower IVC use (OR 0.278, P = 0.018). Overall utilization of IVC after the 2013 European Association of Urology (EAU) guideline was 24% vs. 0% prior to 2013 (P < 0.001). Limitations include limited data regarding IVC timing/agent and inclusion of minimally invasive RNU patients only.
While IVC use has increased since being added to the EAU UTUC guidelines, its use remains low at academic centers, particularly within Europe.
The Impact of Hospital Volume on Short-term and Long-term Outcomes for Patients Undergoing Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma
2021, Urology
To examine the effect of hospital volume on short and long-term outcomes for radical nephroureterectomy (RNUx). Upper tract urothelial carcinoma is a rare malignancy that few surgeons have experience with. The hospital volume-outcome relationship has been well established for other cancers but not RNUx.
The National Cancer Database was queried for all cases of upper tract urothelial carcinoma that underwent RNUx from 2004 to 2016. Average annual hospital volume for radical nephroureterectomy was stratified into tertiles. The upper tertile, defined as 6 or more RNUx per year, was considered high volume while low volume was less than 6 RNUx per year. Kaplan-Meier and Cox proportional hazards regression were used to identify independent predictors of overall survival, and logistic regression was used to identify predictors of perioperative outcomes.
We identified 37,479 RNUx performed across 1290 hospitals. There were no differences in baseline health or cancer staging between patients who presented at low- versus high-volume centers. Both peri-operative survival (30- and 90-day mortality) and long-term overall survival were improved in patients treated at high-volume centers. On multivariable survival analysis, treatment at a high-volume center was associated with improved hazards of survival. This relationship for long-term survival remained consistent on landmark analysis where patients who died within 90 days of surgery were removed.
Treatment at a high-volume hospital was associated not only with improved short-term perioperative outcomes but also with improved overall long-term survival. The mechanism behind this is likely multifactorial with surgeon volume, and ancillary support services all playing critical roles.
Nephroureterectomy with or without Bladder Cuff Excision for Localized Urothelial Carcinoma of the Renal Pelvis
2020, European Urology Focus
Few studies examined the rates of guideline implementation and the survival effect of bladder cuff excision (BCE) at nephroureterectomy (NU).
To assess the rates of guideline implementation regarding NU with BCE relative to NU without BCE in patients with upper tract urothelial carcinoma (UTUC) and to test the effect of BCE on cancer-specific (CSM) and other-cause mortality (OCM).
We relied on Surveillance, Epidemiology, and End Results database (2004–2014) for UTUC of the renal pelvis patients (T1-T3, N0, M0) treated with NU with or without BCE.
Cumulative incidence plots relying on competing-risks methodology illustrated 5-yr CSM and OCM rates. Multivariable competing-risks regression (MCRR) models tested the effect of BCE versus no BCE at NU.
Of 4266 assessable patients, 2913 (68.3%) underwent NU with BCE. Between 2004 and 2014, rates of BCE at NU increased from 63.0% to 74.5% (European Association for Palliative Care: 2%; p < 0.001). At 60 mo, CSM rates were 19.7% versus 23.5% (p = 0.005) in NU with BCE versus NU without BCE patients, respectively. In MCRR models, no difference in CSM was recorded according to BCE at NU (hazard ratio [HR]: 0.88, confidence interval [CI]: 0.75–1.03, p = 0.1). Finally, OCM was unaffected by BCE at NU (HR: 0.94, CI: 0.77–1.15, p = 0.5). This study is retrospective.
According to guideline recommendation, the rates of NU with BCE increased over time. However, BCE status does not appear to affect CSM or OCM. Thus, our study was unable to examine the rates of urothelial cancer recurrence or metastatic progression according to BCE status.
Rates of bladder cuff excision (BCE) at nephroureterectomy (NU) are increasing. This observation confirms improved adherence to guidelines over time. However, BCE status does not appear to affect survival after NU for upper tract urothelial carcinoma.
Oncological Outcomes of Laparoscopic Nephroureterectomy Versus Open Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An European Association of Urology Guidelines Systematic Review
2019, European Urology Focus
Citation Excerpt :
Of these 22 series, five reported a 100% rate of lymph node dissection in both groups [18,25,26,30,35] and three studies reported a 0% rate of lymph node dissection in each group [9,26,28]. Three of the 14 remaining studies reported significantly lower rates of lymphadenectomy in the laparoscopic group [34,41,44], while rates of lymphadenectomy were similar between the open and laparoscopic cases in the other series. Only one study reported a significant difference regarding the number of lymph nodes removed, favouring the open over the laparoscopic approach [19].
Most series have suggested better perioperative outcomes of laparoscopic radical nephroureterectomy (RNU) over open RNU. However, the oncological safety of laparoscopic RNU remains controversial.
To systematically review all relevant literature comparing oncological outcomes of open versus laparoscopic RNU.
A systematic literature search using the Medline, Embase, and Cochrane databases and clinicaltrial.gov was performed in December 2014 and updated in August 2016. Randomised controlled trials (RCTs) and prospective or retrospective nonrandomised comparative studies comparing the oncological outcomes of any laparoscopic RNU with those of open RNU were included. The primary outcome was cancer-specific survival. The risk of bias (RoB) was assessed using Cochrane RoB tools. A narrative synthesis of the evidence is presented.
Overall, 42 studies were included, which accounted for 7554 patients: 4925 in the open groups and 2629 in the laparoscopic groups. Most included studies were retrospective comparative series. Only one RCT was found. RoB and confounding were high in most studies. No study compared the oncological outcomes of robotic RNU with those of open RNU. Bladder cuff excision in laparoscopic groups was performed via an open approach in most studies, with only three studies reporting laparoscopic removal of the bladder cuff. Port-site metastasis rates ranged from 0% to 2.8%. No significant difference in oncological outcomes was reported in most series. However, three studies, including the only RCT, reported significantly poorer oncological outcomes in patients who underwent laparoscopic RNU, especially in the subgroups of patients with locally advanced (pT3/pT4) or high-grade upper tract urothelial carcinoma (UTUC), as well as in instances when the bladder cuff was excised laparoscopically.
The current available evidence suggests that the oncological outcomes of laparoscopic RNU may be poorer than those of open RNU when bladder cuff is excised laparoscopically and in patients with locally advanced high-risk (pT3/pT4 and/or high-grade) UTUC.
We reviewed the literature comparing the outcomes of two different surgical procedures for the treatment of upper tract urothelial carcinoma. Open radical nephroureterectomy is a surgical procedure in which the kidney is removed through a large incision in the abdomen, while in laparoscopic radical nephroureterectomy, the kidney is removed through a number of small incisions. Our findings suggest that the outcomes of laparoscopic radical nephroureterectomy may be poorer than those of open radical nephroureterectomy, particularly when the bladder cuff is also required to be removed. Laparoscopic radical nephroureterectomy may also be less effective in patients with locally advanced (pT3/pT4) or high-grade upper tract urothelial carcinomas.
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Platinum Priority – Urothelial CancerEditorial by Evangelos Liatsikos and Panagiotis Kallidonis on pp. 10–12 of this issueComparison of Oncologic Outcomes for Open and Laparoscopic Nephroureterectomy: A Multi-Institutional Analysis of 1249 Cases

Abstract

Background

Objective

Design, setting, and participants

Measurements

Results and limitations

Conclusions

Introduction

Section snippets

Patient selection

Results

Discussion

Conclusions

Eur Urol

J Urol

J Urol

Urology

Eur Urol

Eur Urol

Urology

Urology

Eur Urol

Eur Urol

Eur Urol

Urology

Eur Urol

Platinum Priority – Urothelial Cancer
Editorial by Evangelos Liatsikos and Panagiotis Kallidonis on pp. 10–12 of this issue
Comparison of Oncologic Outcomes for Open and Laparoscopic Nephroureterectomy: A Multi-Institutional Analysis of 1249 Cases