Robot-Assisted Radical Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma: A Promising Alternative to Open Surgery or a Future “Gold Standard”?

Abstract

Upper urinary tract urothelial carcinomas (UUT-UCs) are uncommon malignancies (1 to 4 new cases per 100,000 persons per year) and account for only 5% to 10% of all urothelial neoplasms. Unlike bladder cancer, about 60% of UUT-UCs are invasive at the time of diagnosis and therefore require a radical surgical treatment in most cases. Open radical nephroureterectomy (ONU) with bladder cuff excision is still the gold standard treatment for UUTUC, regardless of the tumor location in the upper urinary tract. Laparoscopic radical nephroureterectomy (LNU), first described by Clayman et al in 1991, had been proposed as an alternative, minimally invasive option for the surgical management of UUTUC, offering overlapping oncologic results but better perioperative outcomes and improved cosmesis when compared to ONU. Survival benefits of radical nephroureterectomy (RNU) have been widely discussed: the Upper Urinary Tract Urothelial Carcinoma Collaboration Group reported, in those patients who underwent either open or laparoscopic radical nephroureterectomy for UUTUC, overall 5-year recurrence-free survival (RFS) and cancerspecific survival (CSS) rates of 69% and 73%, respectively. The avoidance of tumor spillage and seeding into the operative field, the complete excision of the bladder cuff, and, perhaps, an accurate retroperitoneal or pelvic lymph node dissection are surgical steps of paramount importance that might be achieved in those patients with life-threatening disease, such as high-grade, high-stage, multifocal UUT-UC. Robotic surgery has been recently developed as the natural evolution and simplification of traditional laparoscopy, being able to bridge the technical difficulties related to the handling of laparoscopic instruments and allowing the performance of even challenging or complex urologic procedures. However,