Abstract
PurposeThis 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.MethodsFrom 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.ResultsAmong 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).ConclusionsMinimally 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.
Highlights
Upper tract urothelial carcinoma (UTUC) is a relatively rare malignant tumor, accounting for 5–10% of urothelial carcinoma [1]
The hand-assisted laparoscopic NU (HALNU) group had the lowest rate of lymphadenectomy (17.4%)
The study of Shigeta et al conducted a subgroup analysis and the results showed that cancer-specific survival (CSS) and bladder recurrence-free survival (BRFS) rates of the laparoscopic NU (LNU) group in T3 patients were lower than those of the open NU (ONU) group [13]
Summary
Upper tract urothelial carcinoma (UTUC) is a relatively rare malignant tumor, accounting for 5–10% of urothelial carcinoma [1]. Minimally invasive surgeries (MIS) including hand-assisted laparoscopic NU (HALNU), laparoscopic NU (LNU) and robotic NU (RNU) have been introduced as an alternative to open NU (ONU) and widely accepted for the treatment of UTUC. It is well known that compared with open surgery, the benefits of MIS on perioperative outcomes include lower estimated blood loss, lower blood transfusion rate, shorter hospital stay, less pain, fewer wound complications, and shorter recovery time [4, 5]. The oncological outcomes of MIS for UTUC have been controversial, but most previous studies have shown that the survival rate is not inferior compared with open method, especially for organ-confined UTUC [6, 7]. Compared with other MIS, HALNU is considered to have lower surgical difficulty and similar oncological results, so it is commonly used. The intramural ureter and surgical specimen must be completely removed as a whole to prevent tumor residue and spillage [8]
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