Open Radical Nephroureterectomy Research Articles

Open versus minimally invasive nephroureterectomy in octogenarians: An analysis of surgical approach trends, outcomes, and survival analysis with propensity matching

IntroductionUpper tract urothelial carcinoma (UTUC) is a rare disease accounting only for 5%–10% of urothelial carcinoma (UC). For localized high-risk disease, radical nephroureterectomy (RNU) is the standard of care. While minimally invasive (MIS) RNU has not been shown to decisively improve overall survival (OS) compared to open surgery, MIS RNU has been associated with reduced hospital length of stay (LOS), blood transfusion requirements and improved recovery, which are important considerations when treating older patients.The purpose of this study is to examine trends in surgical approach selection and outcomes of open vs. MIS RNU in patients aged ≥80 years. MethodsUsing the National Cancer Database (NCDB), patients aged ≥80 years who underwent open or MIS (either robotic or laparoscopic) RNU were identified from 2010 to 2019. Demographic, patient-related, and disease-specific factors associated with either open or MIS RNU were assessed using multivariate logistic regression models. Survival analysis was conducted using Kaplan-Meier plots and Cox-proportional hazard regression. Inverse probability of treatment weighting (IPTW) was utilized to adjust for confounding variables. Survival analysis was also conducted on the IPTW adjusted cohort using Kaplan-Meier plots and Cox-proportional hazard regression. Results5,687 patients were identified, with 1,431 (25.2%) and 4,256 (74.8%) patients undergoing open and MIS RNU respectively. The proportion of RNU performed robotically has increased from 12.5% in 2010 to 50.4% in 2019. MIS was associated with a shorter hospital LOS (4.7 days versus 5.9 days, SMD 23.7%). Multivariate analysis revealed that MIS was associated with a significant reduction in 90-day mortality (OR: 0.571; 95%CI: 0.34–0.96, P = 0.033) and improved median OS (53.8 months [95%CI: 50.9–56.9] vs 42.35 months [95%CI: 38.6–46.8], P < 0.001) compared to open surgery. IPTW-adjusted survival analysis revealed improved median OS with MIS when compared to open surgery, with a survival benefit of 46.1 months (95%CI: 40.2–52.4 months) versus 37.7 months (95%CI: 32.6–46.5 months, P = 0.0034) respectively. IPTW-adjusted cox proportional hazard analysis demonstrated that MIS was significantly associated with reduced mortality (HR 0.76, 95%CI: 0.66–0.87, P < 0.001). ConclusionIn octogenarians undergoing RNU, MIS is associated with improved median OS and 90-day mortality.

Changes in the Perioperative Management and Outcomes of Patients With Upper Tract Urothelial Carcinoma Undergoing Radical Nephroureterectomy at Memorial Sloan Kettering Cancer Center: Over 20 Years of Experience.

We evaluated surgical trends, perioperative management evolution, and oncologic outcomes in patients who underwent radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) at a tertiary cancer center over a 24-year period. Between 1995 and 2018, we evaluated 743 consecutive patients with UTUC who underwent RNU. Generalized additive models were used to estimate the associations between date of surgery and continuous outcomes using a linear model, dichotomous outcomes using a logit link, categorical outcomes using multinomial models, and 2- and 5-year survival outcomes using Cox proportional hazards models. Over the study period, preoperative diagnostic endoscopic biopsies increased from 10% to 66%, along with the proportion of patients who underwent RNU for high-grade disease from 55% to 91%. The rate of open RNU declined from 100% to 56% with a rise in minimally invasive approaches. Median lymph node yield increased with more retroperitoneal lymph node dissections performed. Neoadjuvant chemotherapy utilization increased with a contemporary utilization rate of 32%, coinciding with an increase in pT0 rate from 2% to 8%. Cancer-specific survival probabilities improved over the study period, while metastasis-free and overall survival remained stable. We found several changes in treatment patterns and outcomes for patients with UTUC over the past 2 decades. How individual alterations in management factors, such as patient selection, perioperative chemotherapy, lymphadenectomy, and salvage therapies, impact patient outcomes is challenging in the setting of multiple overlapping practice changes for this rare disease and warrants further investigation.

Oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma: a literature review.

Radical nephroureterectomy (RNU) represents the gold standard treatment for non-metastatic upper tract urothelial cancer. We sought to provide a comprehensive review of reported oncologic outcomes of the RNU procedure and of factors that might impact these outcomes. A non-systematic review of the literature was conducted by performing an electronic literature search using PubMed with "radical nephroureterectomy" and "oncologic outcomes" as free text search terms. Both original articles and systematic reviews were considered. Search was limited to articles in English that were published in the last 20 years. Open and laparoscopic RNU offer comparable oncologic outcomes. In more recent years, the discussion has de facto shifted towards the "oncological safety" of robotic RNU, which also seems to offer comparable oncologic outcomes. Several studies have looked at the impact of different treatment-, patient- and tumor-related factors. Among treatment-related factors, attention has been given to diagnostic ureteroscopy and the risk of intravesical recurrence. Surgical wait time and perioperative blood transfusion have also been studied. Perioperative chemotherapy, specifically adjuvant therapy, was shown to improve survival. Among patient-related factors, baseline chronic kidney disease, diabetes mellitus, body mass index, and systemic inflammation have gained recent attention. Some tumor related factors, such as stage, grade, location, and multifocality may negatively impact survival outcomes. Lymphovascular invasion and histologic variants are clinically significant pathological findings. RNU is a procedure with measured long-term oncologic outcomes. Minimally invasive techniques have gained an established role as they seem to offer comparable oncologic "safety", although special attention is needed in relation to the method of bladder cuff excision. Robotic RNU is gaining popularity, and while evidence remains limited, the current literature supports the oncologic safety of this procedure. Several factors, which can be categorized as treatment-related, patient-related, and tumor-related, might impact the oncologic outcomes of UTUC patients undergoing RNU. These factors can provide crucial information to stratify patients based on their relative risk of disease recurrence and mortality which may guide clinical decision-making.

Case Report: Metachronous bilateral upper tract and bladder urothelial carcinoma: a long-term follow-up

Background: Upper tract urothelial carcinoma (UTUC) is a malignant disease of the urothelial cell lining the upper urinary tract from renal calyces, pelvises, and ureter down to the ureteral orifice. Urothelial carcinoma is a multifocal malignant tumor which tends to reoccur after treatment. Radical cystectomy shows that upper tract recurrence occurs in 0.75% to 6.4% of patients. The occurrence of contralateral UTUC after nephroureterectomy is rarer with a prevalence of 0.5%. Case presentation: The case of a 43-year-old male with metachronous bilateral UTUC was reported. The patient had undergone gemcitabine-cysplatine neoadjuvant chemotherapy followed by radical cystectomy and orthotopic neobladder for urothelial carcinoma of the bladder cT2N0M0. Left hydronephrosis was discovered three months after the procedure. The patient was diagnosed with left UTUC cT4N0M0 of renal pyelum after a series of examinations. A left open radical nephroureterectomy was conducted to remove the mass followed by adjuvant chemotherapy. This was followed up with routine ultrasound and magnetic resonance imaging (MRI) every three months with a “tumor-free” period of 26 months. Meanwhile, the patient was re-admitted with fever and an increase in creatinine value of 4.3. After further workups, the patient was diagnosed with UTUC cT2N0M0 of the right renal pyelum. A kidney sparring approach with laser evaporation of the tumor was conducted followed by eight cycles of Gemcitabine intracavity antegrade per nephrostomy. After the regimen was finished, an MRI evaluation was conducted to assess treatment results, and the mass had decreased. Conclusions: This report showed a rare case of urothelial cell carcinoma recurrences. From bladder urothelial carcinoma to left UTUC and then to contralateral UTUC. It is important to evaluate the upper tract to reduce the risk of recurrence.

Surgical techniques and oncological outcomes of pure transperitoneal laparoscopic radical nephroureterectomy for upper urinary tract urothelial carcinoma.

Open radical nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for upper urinary tract urothelial carcinoma (UTUC). Traditional laparoscopic radical nephroureterectomy (LSRNU) is not minimally invasive enough due to the complex surgical procedure. This study aims to discuss the clinical feasibility and oncological outcomes of pure transperitoneal LSRNU for UTUC. Between July 2010 and December 2020, 115 patients were admitted to the hospital with the diagnosis of UTUC treated with pure LSRNU by one surgeon. A special laparoscopic bulldog clamp was placed at the bladder cuff before cutting and suturing. The clinical and follow-up data were preoperatively collected and analyzed. Overall survival (OS) and cancer-specific survival (CSS) were estimated by the Kaplan-Meier method. All surgeries were completed uneventfully in this cohort. The mean operative time was 145.69 minutes. The mean estimated blood loss was 56.61 mL. The mean removal time of the drain was 3.46 days. The mean time of having liquid diet was 1.32 days, and the ambulation time was 1.50 days. All surgeries were effectively completed, and no case required open conversion. According to the Clavien-Dindo classification system, postoperative complications occurred in two patients (II, III). The mean length of postoperative hospital stay was 5.78 days. The mean follow-up duration was 54.50 months. Recurrence in the bladder was 16.0% (15/94), compared with 4.6% (4/87) in the contralateral upper tract. The 5-year OS and CSS rates were 78.9% and 81.4%, respectively. Pure transperitoneal LSRNU is a safe and effective minimally invasive technology for the treatment of UTUC.

PD46-12 COMPARING THE PERIOPERATIVE OUTCOMES OF OPEN RADICAL NEPHROURETERECTOMY AND ROBOT ASSISTED NEPHROURETERECTOMY USING PROPENSITY SCORE MATCH ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD46-12 COMPARING THE PERIOPERATIVE OUTCOMES OF OPEN RADICAL NEPHROURETERECTOMY AND ROBOT ASSISTED NEPHROURETERECTOMY USING PROPENSITY SCORE MATCH ANALYSIS Sheshang Kamath, Abhinav Veerwal, Akash Shah, and Thyavihally Yuvaraja Sheshang KamathSheshang Kamath More articles by this author , Abhinav VeerwalAbhinav Veerwal More articles by this author , Akash ShahAkash Shah More articles by this author , and Thyavihally YuvarajaThyavihally Yuvaraja More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003359.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although Open radical nephroureterectomy (O-RNU) with bladder cuff excision (BCE) remains the gold standard for management of management of upper tract urothelial carcinoma, the trend has been changing globally towards minimal invasive surgery after the meta- analysis published by the European guidelines. We intend to specifically evaluate the intraoperative and post-operative aspects of Robot assisted nephroureterectomy (RANU) with BCE with respect to O-RNU with BCE for wider application RANU if feasible. METHODS: This study is a retrospectives study, the data of which was obtained from a prospectively maintained cancer registry of the oncology department in our tertiary care institute. The data was obtained between January 2011 and July 2022 from a single center operated by a single surgeon to avoid surgeon and institution bias. Univariate analysis was performed for baseline parameters, pathologic and perioperative outcomes among the two groups using Chi square test for categorical variables and student t-test was used for continuous variables. Multivariate logistic regression analysis was then performed. Propensity score match analysis (PSM) 1:1 was used to independently evaluate the lymph node yield, postoperative complications of Clavien Dindo grade 3 and above and time to discharge from the hospital after matching for the patient and tumor characteristics. The value of p considered significant was<0.05. RESULTS: Among 352 patients, 288 O-RNU and 64 RANU were performed. Median age of patient was 69 (IQR 54-71) in O-RNU and 70 (IQR 56-73) in RANU. Most common tumor stage for both arms was T2 (46.2 % in O-RNU vs 51.5% in RANU) Total operative time among both groups was higher in open surgery (180±17 minutes in O-RNU vs 153±10 minutes in RANU. Perioperative factors significantly improved among RANU group was lymph node yield, Clavien Dindo complications 3 or more and time to discharge in multivariate logistic regression. PSM 1:1 done for 64 nephroureterectomies in each group matched for baseline patient and tumor variables found only time to discharge and readmission rates to be significantly lesser in the RANU group. CONCLUSIONS: Although cost of surgery increases, propensity score analysis shows readmission rates and hospital stay significantly lesser in the robotic group, thereby significantly impacting the post-operative wellbeing of the patients. The retrospective nature of the study remains a drawback of this study, however we feel this study should urge more intuitions across the globe to start implementing RANU to give a prospective and global perspective. Source of Funding: We have no source of funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1174 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sheshang Kamath More articles by this author Abhinav Veerwal More articles by this author Akash Shah More articles by this author Thyavihally Yuvaraja More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparing Oncological and Perioperative Outcomes of Open versus Laparoscopic versus Robotic Radical Nephroureterectomy for the Treatment of Upper Tract Urothelial Carcinoma: A Multicenter, Multinational, Propensity Score-Matched Analysis

To identify correlates of survival and perioperative outcomes of upper tract urothelial carcinoma (UTUC) patients undergoing open (ORNU), laparoscopic (LRNU), and robotic (RRNU) radical nephroureterectomy (RNU). We conducted a retrospective, multicenter study that included non-metastatic UTUC patients who underwent RNU between 1990-2020. Multiple imputation by chained equations was used to impute missing data. Patients were divided into three groups based on their surgical treatment and were adjusted by 1:1:1 propensity score matching (PSM). Survival outcomes per group were estimated for recurrence-free survival (RFS), bladder recurrence-free survival (BRFS), cancer-specific survival (CSS), and overall survival (OS). Perioperative outcomes: Intraoperative blood loss, hospital length of stay (LOS), and overall (OPC) and major postoperative complications (MPCs; defined as Clavien-Dindo > 3) were assessed between groups. Of the 2434 patients included, 756 remained after PSM with 252 in each group. The three groups had similar baseline clinicopathological characteristics. The median follow-up was 32 months. Kaplan-Meier and log-rank tests demonstrated similar RFS, CSS, and OS between groups. BRFS was found to be superior with ORNU. Using multivariable regression analyses, LRNU and RRNU were independently associated with worse BRFS (HR 1.66, 95% CI 1.22-2.28, p = 0.001 and HR 1.73, 95%CI 1.22-2.47, p = 0.002, respectively). LRNU and RRNU were associated with a significantly shorter LOS (beta -1.1, 95% CI -2.2-0.02, p = 0.047 and beta -6.1, 95% CI -7.2-5.0, p < 0.001, respectively) and fewer MPCs (OR 0.5, 95% CI 0.31-0.79, p = 0.003 and OR 0.27, 95% CI 0.16-0.46, p < 0.001, respectively). In this large international cohort, we demonstrated similar RFS, CSS, and OS among ORNU, LRNU, and RRNU. However, LRNU and RRNU were associated with significantly worse BRFS, but a shorter LOS and fewer MPCs.

Laparoscopic Radical nephroureterectomy for Upper Renal Excretory Tract urothelial Carcinoma: Results from a single Center in Douala Cameroon

Background and aim: Upper Tract Urothelial Carcinoma (UTUC) which represent 5-10% of urothelial tumours are tumours that develop in the urothelium of the pyelocalicial cavities or the ureters. The standard surgical treatment is total open radical nephroureterectomy with excision of the bladder collar. The development of minimally invasive surgery, such as laparoscopic surgery and its contribution to the management of renal pathologies has allowed the adaptation of this technique in the treatment of tumours of the upper excretory tracts. We present the epidemiological, clinical, paraclinical, therapeutic and evolutionary characteristics of patients with upper excretory tract tumours treated by laparoscopic nephroureterectomy. Methods: This prospective single-center study included 5 patients with UTUC treated at the Centre medico-chirugical d’urologie in Douala, Cameroon between 2016 and 2021. Results: We included 4 men and 1 woman, with a mean age of 62.4±3.85 years. Four (80%) patients had a history of tobacco and 3(60%) had a history of repeated urinary tract infections. The main reasons for consultation were gross haematuria and renal colic-type lumbar pain. In all cases, the diagnosis was made by the triad of thoracic and abdominal CT scan, cystoscopy and semi-rigid ureteroscopy. Four (80%) patients had tumours in the ureter and 3(60%) patients had an associated bladder tumour. The treatment consisted of transperitoneal laparoscopic nephroureterectomy with resection of the bladder collar via a double lumbar and iliac approach. The median surgery duration was 300[270-330] minutes and there were no major immediate post-operative complications. Histopathology confirmed that all 5 cases were urothelia carcinomas. Recurrence was observed in 4(80%) patients and 3(60%) patients died from disease progression, with a median survival time of 17.93 months. Conclusion: Laparoscopic total nephroureterectomy with resection of the bladder collar is an important alternative to open surgery in the treatment of tumours of the upper excretory tract as it reduces operating time, length of hospital stay, and the occurrence of complications. The prognosis of these tumours depends on the stage and grade with a significant potential for recurrence indicating the need for regular and prolonged monitoring.

SC225 - Contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy in patients with upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy: analysis of us claims on perioperative outcomes and health care costs

SC225 - Contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy in patients with upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy: analysis of us claims on perioperative outcomes and health care costs

Comparison of survival outcomes between laparoscopic versus open radical nephroureterectomy in upper tract urothelial cancer patients: Experiences of a tertiary care single center.

To test for differences in overall and recurrence-free survival between laparoscopic and open surgical approaches in patients undergoing radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). We retrospectively identified patients treated for UTUC from 2010 to 2020 from our institutional database. Patients undergoing laparoscopic or open RNU with no suspicion of metastasis (cM0) were for the current study population. Patients with suspected metastases at diagnosis (cM1) or those undergoing other surgical treatments were excluded. Tabulation was performed according to the laparoscopic versus open surgical approach. Kaplan-Meier plots were used to test for differences in overall and recurrence-free survival with regard to the surgical approach. Furthermore, separate Kaplan-Meier plots were used to test the effect of preoperative ureterorenoscopy on overall and recurrence-free survival within the overall study cohort. Of the 59 patients who underwent nephroureterectomy, 29% (n = 17) underwent laparoscopic nephroureterectomy, whereas 71% (n = 42) underwent open nephroureterectomy. Patient and tumor characteristics were comparable between groups (p ≥ 0.2). The median overall survival was 93 and 73 months in the laparoscopic nephroureterectomy group compared to the open nephroureterectomy group (p = 0.5), respectively. The median recurrence-free survival did not differ between open and laparoscopic nephroureterectomies (73 months for both groups; p = 0.9). Furthermore, the median overall and recurrence-free survival rates did not differ between patients treated with and without preoperative ureterorenoscopy. The results of this retrospective, single-center institution showed that overall and recurrence-free survival rates did not differ between patients with UTUC treated with laparoscopic and open RNU. Furthermore, preoperative ureterorenoscopy before RNU was not associated with higher overall or recurrence-free survival rates.

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

Simple SummaryRobotic radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma has only recently started to increase in Korea. The use of robotic RNU has been steadily increasing from 9% in 2017 to 67% in 2021 in our institution and replacing open and laparoscopic RNU. Perioperative outcomes including operation time, blood loss, and the length of hospital stay were not different between the robotic, open, and laparoscopic RNU groups. The 90-day complications did not differ significantly 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 intravesical recurrence-free survival, progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS) were observed according to the surgical approach in the Kaplan–Meier survival analysis. Multivariate analysis showed that the surgical approach of RNU was not an independent predictor of PFS, CSS, and OS.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.

Contemporary Trends of Systemic Neoadjuvant and Adjuvant Intravesical Chemotherapy in Patients With Upper Tract Urothelial Carcinomas Undergoing Minimally Invasive or Open Radical Nephroureterectomy: Analysis of US Claims on Perioperative Outcomes and Health Care Costs.

New evidence indicates that minimally invasive surgery (MIS) (laparoscopic or robotic-assisted [LNU, RANU]) reaches oncologic equivalence compared with Open Radical Nephroureterectomy (ORNU) for high-risk upper-tract urothelial carcinoma (UTUC). Recently, European Association of Urology (EAU) Guidelines suggested implementing neoadjuvant chemotherapy (NAC) to standard treatment to improve oncologic outcomes of high-risk UTUC. We aimed (1) To explore contemporary trends of MIS for RNU in the United States and to compare perioperative outcomes and costs with that of ORNU. (2) To determine the trends of NAC and postoperative intravesical chemotherapy (PIC) administration for high-risk UTUC and to assess their contribution to perioperative outcomes and costs. The Optum Clinformatics Data Mart de-identified database was queried from 2003 to 2018 to retrospectively examine patients who had undergone LNU/RANU or ORNU with or without NAC and PIC. We evaluated temporal adoption trends, complications, and health care cost analyses. We obtained descriptive statistics and utilized multivariable regression modeling to assess outcomes. A total of n=492 ORNU and n=1618 LNU/RANU procedures were reviewed. The MIS approach was associated with a statistically significant lower risk of intraoperative complications (adjusted Odds Ratio [aOR], 0.48, 95% CI:0.24-0.96), risk of hospitalization costs (aOR: 0.62, 95% CI:0.49-0.78), and shorter hospital stay (aOR: 0.20, 95% CI:0.15-0.26) when compared to ORNU. Overall, adoption of NAC and PIC accounted for only n=81 and n < 37 cases respectively. The implementation of NAC and higher number of cycles were associated with an increased probability of any complication rate (aOR: 2.06, 95% CI:1.26-3.36) and hospital costs (aOR: 2.12, 95% CI:1.33-3.38). MIS has become the approach of choice for RNU in the US. Although recommended by guidelines, neither NAC nor postoperative bladder instillation of chemotherapy has been routinely incorporated into the clinical practice of patients with UTUC.

A comparison of perioperative outcomes of laparoscopic versus open nephroureterectomy for upper tract urothelial carcinoma: a propensity score matching analysis.

Radical nephroureterectomy (RNU) with the concomitant excision of the distal ureter and bladder cuff is the current standard of care for the treatment of muscle invasive and/or high-risk upper tract urothelial carcinoma (UTUC). In small uncontrolled studies, laparoscopic RNU has been suggested to be associated with better perioperative outcomes compared to open RNU. The aim of our study was to compare the perioperative oncological and functional outcomes of open RNU versus laparoscopic RNU after adjusting for preoperative baseline patient-related characteristics. We evaluated a multi-institutional retrospective database composed by 1512 patients diagnosed with UTUC and treated with open or laparoscopic RNU between 1990 and 2016. Perioperative outcomes included operative time, blood loss, and length of hospital stay, as well as postoperative complications, readmission, reoperation, and mortality rates at 30 and 90 days from surgery. A 1:1 propensity score matching estimated using logistic regression with the teffects psmatch function of STATA 13® (caliper 0.2, no replacement; StataCorp LLC; College Station, TX, USA) was performed using preoperative parameters such as: age, gender, Body Mass Index (BMI), and American Society of Anesthesiologists (ASA) Score. Overall, 1007 (66.6%) patients were treated with open and 505 (33.4%) with laparoscopic RNU. Open RNU resulted into shorter median operative time (180 vs. 230 min, P<0.001) and longer median hospital stay (10 vs. 7 days, P<0.001) in comparison to laparoscopic RNU. No statistically significant difference was identified for the other variables of interest (all P>0.05). At multivariable linear regression after propensity score matching adjusted for lymph node dissection and year of surgery, laparoscopic RNU resulted in longer operative time (coefficient 43.6, 95% CI 27.9-59.3, P<0.001) and shorter hospital stay (coefficient -1.27, 95% CI -2.1 to -0.3, P=0.01) compared to open RNU, but the risk of other perioperative complications remained similar between the two treatments. Laparoscopic RNU is associated with shorter hospital stay, but longer operative time in comparison to open RNU. Otherwise, there were no differences in other perioperative outcomes between these surgical modalities even after propensity score matching. The choice to offer laparoscopic or open RNU in the treatment of UTUC should not be based on concerns of different safety outcomes.

A0299 - Contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy for upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy: US-claims analysis on perioperative and health care costs outcomes

A0299 - Contemporary trends of systemic neoadjuvant and adjuvant intravesical chemotherapy for upper tract urothelial carcinomas undergoing minimally invasive or open radical nephroureterectomy: US-claims analysis on perioperative and health care costs outcomes

Perioperative and oncological outcomes of laparoscopic and open radical nephroureterectomy for locally advanced upper tract urothelial carcinoma: a single-center cohort study.

Open radical nephroureterectomy (ONU) is the standard of care for treatment of upper tract urothelial carcinoma (UTUC), but laparoscopic radical nephroureterectomy (LNU) is increasingly being used due to better perioperative outcomes. However, its oncological safety remains controversial, in particular for advanced disease.We aimed to compare perioperative and oncological outcomes between surgical approaches in locally advanced UTUC (≥pT3 and/or pN+). This study was a retrospective analysis of all 48 patients submitted to radical nephroureterectomy for advanced UTUC between 2006 and 2020 in our center.Perioperative data were compared between groups. Bladder tumor-free survival (BTFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) were estimated using Kaplan-Meier curves and compared with log-rank p test. Multivariable Cox regression model was used to evaluate their association with surgical approach. Clinical and pathological characteristics were similar between groups. LNU had lower blood loss (p = 0.031), need for transfusion (p = 0.013) and length of hospital stay (p <0.001), with similar operative time (p = 0.860).LNU was associated with better MFS (hazard ratio [HR]: 0.43, 95% confidence interval [CI] 0.20-0.93, p = 0.033) and CSS (HR: 0.42, 95%CI 0.19-0.94, p = 0.036). Median time to cancer death was 41 months for LNU and 12 months for ONU (log-rank p = 0.029). BTFS was similar between groups (HR: 0.60, 95%CI 0.17-2.11, p = 0.427). On multivariable Cox regression model, surgical approach wasn't significantly associated with MFS (p = 0.202), CSS (p = 0.149) or BTFS (p = 0.586). In our cohort of advanced UTUC, LNU did not result in inferior oncological control compared to ONU. The minimally invasive approach conferred an advantage in perioperative outcomes.

Comparison of Tumor Seeding and Recurrence Rate After Laparoscopic vs. Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma

Introduction: Laparoscopic surgery for Upper Urinary Tract Urothelial Cell Carcinoma (UTUC) is still debated for its possible seeding risk and thus consequent oncological recurrences, especially for atypical ones. The aim of the study is to compare recurrence and survival after Laparoscopic vs. Open Radical Nephroureterectomy (RNU) for Upper Urinary Tract Urothelial Cancer (UTUC).Method: A retrospective evaluation of UTUC consecutive surgeries from 2008 to 2019 was conducted, including pT ≥ 2, High Grade UTUC who underwent RNU with bladder cuff excision without concomitant lymphadenectomy in three urological tertiary centers. Statistical analyses compared recurrence and cancer specific survival, based on surgical approach, while logistic multivariate analyses and Kaplan Meyer survival curve analyzed possible risk factors for recurrence and survival.Results: One hundred seven cases of RNU, 47 (43.9%) laparoscopic and 60 (56.1%) open, were included in this report. Preoperative characteristics were comparable between groups. However, tumor stage was higher in the Open arm [T3–T4 in 44 (73.3%) vs. 20 (43.4%) in Laparoscopic]. Mean follow-up was 91.6 months in laparoscopy RNU vs. 93.5 months in open RNU. Recurrence rate (RR) was comparable between groups (p = 0.594), and so was the site, although 3 (6.3%) peritoneal recurrences were found only in laparoscopic group (p = 0.057). At multivariate logistic regression, tumor stage and surgical approach were independent predictors of recurrence (p < 0.05), while only tumor stage was predictor of cancer specific death (p = 0.029).Conclusion: Surgical approach has no impact on recurrence site, overall survival, and RR. Still, according to our data peritoneal carcinomatosis was present only in laparoscopic arm, despite how it didn't reach statistical significance.

Less invasive and equivalent short-term outcomes with simultaneous en bloc robot-assisted radical cystectomy and laparoscopic nephroureterectomy: Comparison with conventional open radical cystectomy and nephroureterectomy.

To clarify the safety and efficacy of en bloc simultaneous robot-assisted radical cystectomy (RARC) and laparoscopic nephroureterectomy (LNU) for synchronous muscle-invasive bladder carcinoma and upper tract urothelial carcinoma (UTUC) or UTUC of a solitary kidney, we evaluated the perioperative and short-term outcomes of this surgical procedure compared with those of simultaneous open radical cystectomy and nephroureterectomy. We prospectively enrolled consecutive patients receiving en bloc simultaneous RARC and LNU between December 2018 and March 2020 at two institutes. Patients' characteristics, surgical, perioperative, and pathological outcomes and recurrence rate within 6months were compared with a historical control receiving simultaneous open radical cystectomy and nephroureterectomy. Ten patients receiving simultaneous RARC and LNU and 17 receiving simultaneous open radical cystectomy and nephroureterectomy were included in the study. Simultaneous RARC and LNU significantly reduced bleeding volume and blood transfusion (P < .0001, P < .0001, respectively) and significantly prolonged operating time (P=.035). RARC and LNU significantly shortened hospitalization after operation (P=.003) and showed reduced tendency of postoperative complications within 30 days but not significantly (P=.25). Pathological characteristics and recurrence within 6months were not significantly different between the two groups. Our results suggested that en bloc simultaneous RARC and LNU were safer surgical procedures with equivalent short-term oncological outcomes compared to conventional open procedures. It can be a standard minimally invasive surgical method in countries where robot-assisted radical nephroureterectomy is inaccessible.

SC138 - Radical nephroureterectomy pentafecta: a proposal for standardisation of oncologic outcomes reporting following open, laparoscopic or robot-assisted radical nephroureterectomy

SC138 - Radical nephroureterectomy pentafecta: a proposal for standardisation of oncologic outcomes reporting following open, laparoscopic or robot-assisted radical nephroureterectomy

Case Report: Metachronous bilateral upper tract and bladder urothelial carcinoma: a long-term follow-up

Background: Upper tract urothelial carcinoma (UTUC) is a malignant disease of the urothelial cell lining the upper urinary tract from renal calyces, pelvises, and ureter down to the ureteral orifice. Urothelial carcinoma is a multifocal malignant tumor which tends to reoccur after treatment. Radical cystectomy shows that upper tract recurrence occurs in 0.75% to 6.4% of patients. The occurrence of contralateral UTUC after nephroureterectomy is rarer with a prevalence of 0.5%. Case presentation: The case of a 43-year-old male with metachronous bilateral UTUC was reported. The patient had undergone gemcitabine-cysplatine neoadjuvant chemotherapy followed by radical cystectomy and orthotopic neobladder for urothelial carcinoma of the bladder cT2N0M0. Left hydronephrosis was discovered three months after the procedure. The patient was diagnosed with left UTUC cT4N0M0 of renal pyelum after a series of examinations. A left open radical nephroureterectomy was conducted to remove the mass followed by adjuvant chemotherapy. This was followed up with routine ultrasound and magnetic resonance imaging (MRI) every three months with a “tumor-free” period of 26 months. Meanwhile, the patient was re-admitted with fever and an increase in creatinine value of 4.3. After further workups, the patient was diagnosed with UTUC cT2N0M0 of the right renal pyelum. A kidney sparring approach with laser evaporation of the tumor was conducted followed by eight cycles of Gemcitabine intracavity antegrade per nephrostomy. After the regimen was finished, an MRI evaluation was conducted to assess treatment results, and the mass had decreased. Conclusions: This report showed a rare case of urothelial cell carcinoma recurrences. From bladder urothelial carcinoma to left UTUC and then to contralateral UTUC. It is important to evaluate the upper tract to reduce the risk of recurrence.

Radical Nephroureterectomy: A Clinical Image

Upper Urinary Tract Urothelial Carcinoma (UTUC) remain rare. Radical Nephroureterectomy (RNU) is the Gold standard for management of these tumours. We are reporting a clinical image of a 45-year-old patient admitted in emergency for left lumbar pain (nephritic colic). The checkups requested computed tomography scanner showed a nephromegaly and left hydronephrosis upstream of a suspicious parietal thickening of the lumbar ureter with cortical and functional repercussion, neighborhood infiltration, and atypical lateral-aortic ganglia. Left lower calicial lithiasis of stasis, pancreatic nodular lesion and the left adrenal gland. The patient was a candidate for an open Radical Left Nephroureterectomy (RNU) (Figure 1). Figure 1: Radical Nephroureterectomy (RNU) picture U (Ureter) R (Renal). There are prognostic factors of tumors of the upper urinary excretory tract, which are the patient’s status, the preoperative, the operation and the anatomopathology [1]. According to current literature data, the oncology outcomes of radical nephrouretrectomy by laparoscopic are lower than those of open RNU surgery [2].