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
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.
References (26)
- et al.
EAU guidelines on diagnosis and treatment of upper urinary tract transitional cell carcinoma
Eur Urol
(2004) - et al.
Upper tract urothelial neoplasms: incidence and survival during the last 2 decades
J Urol
(2000) - et al.
Comprehensive prospective comparative analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to 2005
J Urol
(2008) - et al.
Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy
Urology
(2008) - et al.
Laparoscopic and robotic assisted radical prostatectomy – critical analysis of the results
Eur Urol
(2006) - et al.
Laparoscopic and robotic assisted radical cystectomy for bladder cancer: a critical analysis
Eur Urol
(2008) - et al.
Oncologic control after open or laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: a single center experience
Urology
(2007) - et al.
Comparative study of oncologic outcome of laparoscopic nephroureterectomy and standard nephroureterectomy for upper urinary tract transitional cell carcinoma
Urology
(2007) - et al.
Long-term oncologic outcome after laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma
Eur Urol
(2007) - et al.
Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: comparison of laparoscopic and open surgery
Eur Urol
(2006)
Significant predictive factors for prognosis of primary upper urinary tract cancer after radical nephroureterectomy in Taiwanese patients
Eur Urol
Laparoscopic cytoreductive nephrectomy: the M. D. Anderson Cancer Center experience
Urology
Prognostic value of lymph node dissection in patients with muscle-invasive transitional cell carcinoma of the upper urinary tract
Eur Urol
Cited by (150)
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 InvestigationsCitation 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.
Nephroureterectomy with or without Bladder Cuff Excision for Localized Urothelial Carcinoma of the Renal Pelvis
2020, European Urology FocusOncological Outcomes of Laparoscopic Nephroureterectomy Versus Open Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An European Association of Urology Guidelines Systematic Review
2019, European Urology FocusCitation 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].