Elsevier

European Urology

Volume 58, Issue 5, November 2010, Pages 645-651
European Urology

Platinum Priority – Urothelial Cancer
Editorial by Amnon Zisman on pp. 652–653 of this issue
Comparison Between Laparoscopic and Open Radical Nephroureterectomy in a Contemporary Group of Patients: Are Recurrence and Disease-Specific Survival Associated with Surgical Technique?

https://doi.org/10.1016/j.eururo.2010.08.005Get rights and content

Abstract

Background

Open radical nephroureterectomy (ORN) is the current standard of care for upper tract urothelial carcinoma (UTUC), but laparoscopic radical nephroureterectomy (LRN) is emerging as a minimally invasive alternative. Questions remain regarding the oncologic safety of LRN and its relative equivalence to ORN.

Objective

Our aim was to compare recurrence-free and disease-specific survival between ORN and LRN.

Design, setting, and participants

We retrospectively analyzed data from 324 consecutive patients treated with radical nephroureterectomy (RN) between 1995 and 2008 at a major cancer center. Patients with previous invasive bladder cancer or contralateral UTUC were excluded. Descriptive data are provided for 112 patients who underwent ORN from 1995 to 2001 (pre-LRN era). Comparative analyses were restricted to patients who underwent ORN (n = 109) or LRN (n = 53) from 2002 to 2008. Median follow-up for patients without disease recurrence was 23 mo.

Intervention

All patients underwent RN.

Measurements

Recurrence was categorized as bladder-only recurrence or any recurrence (bladder, contralateral kidney, operative site, regional lymph nodes, or distant metastasis). Recurrence-free probabilities were estimated using Kaplan-Meier methods. A multivariable Cox model was used to evaluate the association between surgical approach and disease recurrence. The probability of disease-specific death was estimated using the cumulative incidence function.

Results and limitations

Clinical and pathologic characteristics were similar for all patients. The recurrence-free probabilities were similar between ORN and LRN (2-yr estimates: 38% and 42%, respectively; p = 0.9 by log-rank test). On multivariable analysis, the surgical approach was not significantly associated with disease recurrence (hazard ratio [HR]: 0.88 for LRN vs ORN; 95% confidence interval [CI], 0.57–1.38; p = 0.6). There was no significant difference in bladder-only recurrence (HR: 0.78 for LRN vs ORN; 95% CI, 0.46–1.34; p = 0.4) or disease-specific mortality (p = 0.9). This study is limited by its retrospective nature.

Conclusions

Based on the results of this retrospective study, no evidence indicates that oncologic control is compromised for patients treated with LRN in comparison with ORN.

Introduction

Open radical nephroureterectomy (ORN) with excision of the distal ureter and bladder cuff is considered the current standard of care for the treatment of nonmetastatic upper tract urothelial carcinoma (UTUC) [1]. However, ORN has been associated with significant morbidity. Laparoscopy has been shown to be equally effective as open surgery for some urologic malignancies while resulting in less perioperative morbidity [2]. In 1991, Clayman et al first described the technique of laparoscopic nephroureterectomy (LRN), and since then it has emerged as an accepted minimally invasive treatment alternative to ORN. However, the oncologic efficacy of LRN and its equivalence to ORN have not been established.

UTUC is a biologically aggressive malignancy with a high potential for disease recurrence and eventual death. Some investigators have hypothesized that tumor dissection and high-pressure pneumoperitoneum during LRN are associated with a higher risk of bladder and/or local recurrence as well as port-site metastasis [3]. The differential effect of LRN versus ORN on oncologic outcomes after radical nephroureterectomy (RN) remains controversial. Although several recent studies suggested comparable oncologic results between ORN and LRN in well-selected patients [4], [5], [6], [7], [8], [9], [10], others reported a higher risk of intravesical disease recurrence with LRN as compared with ORN [11], [12], [13].

We hypothesized that there is no difference in clinical outcomes between ORN and LRN when performed by expert surgeons. To test this hypothesis, we studied the effect of surgical approach on bladder-only recurrence, any recurrence, and disease-specific survival at a single cancer center with genitourinary surgeons and pathologists.

Section snippets

Patient selection and technique

In this study approved by the institutional review board, we retrospectively reviewed all the prospectively collected data on 324 consecutive patients treated with RN at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1995 and 2008. The first LRN was performed in our institution in 2002. Because the aim of the study was to assess the differential effect of surgical approach on oncologic outcomes, we restricted our analyses to patients who underwent ORN or LRN from 2002 to 2008.

Results

In the cohort of 274 patients who underwent RN without prior or concurrent radical cystectomy, 95 (35%) had primary non–muscle-invasive bladder cancer (NMIBC; Table 1). Those with primary bladder cancer were more likely than patients with primary UTUC to have an ASA class of ≥3 (57% vs 42%); there were no other differences between the two groups.

In comparison with the historical ORN cohort, the contemporary ORN cohort was more likely to have a lymph node dissection (81% vs 50%) and shorter

Discussion

Some investigators have suggested that tumor manipulation during LRN may lead to increased gravitational migration of tumor cells and eventual implantation in the bladder. In addition, the high-pressure environment required for the laparoscopic procedure could allow tumor cells to spread through pressurized aerosolization [3]. It is known that the development of secondary bladder cancer after primary UTUC can occur in up to 50% of the patients, mainly due to tumor cells seeding [15].

Conclusions

Based on our retrospective analysis of trained genitourinary oncologic surgeons, no evidence indicates that oncologic control is compromised for patients treated with LRN in comparison with ORN. Despite a well-controlled design, our study lacks a sufficient number of patients treated with LRN as well as a longer follow-up. Well-controlled multi-institutional randomized trials are needed to validate LRN as an oncologically efficacious procedure for patients with UTUC.

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  • 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 :

    Lymph node dissections were rarely performed and homogeneously distributed between open and laparoscopic groups. Bladder cuff excision in laparoscopic groups was performed via an open approach in most studies (16/33, combined RNU), with only three studies reporting laparoscopic extravesical removal of the bladder cuff in all patients [9,36,47] (pure laparoscopic RNU) and four studies reporting laparoscopic removal of the bladder cuff in a minority of patients [19,30,32,38]. The distal ureter was managed endoscopically in four studies [13–15,30] (laparoscopic RNU with endoscopic bladder cuff excision).

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