A retrospective multicenter comparison of conditional cancer-specific survival between laparoscopic and open radical nephroureterectomy in locally advanced upper tract urothelial carcinoma

Abstract

Background Upper urinary tract urothelial carcinomas are relatively rare and have a cancer-specific survival rate of 20%–30%. The current gold standard treatment for nonmetastatic high-grade urinary tract urothelial carcinoma is radical nephroureterectomy with bladder cuff resection. Objective This study aimed to compare conditional cancer-specific survival between open radical nephroureterectomy and laparoscopic radical nephroureterectomy in patients with nonmetastatic stage pT3-4 or TxN(+) locally advanced urinary tract urothelial carcinoma from five tertiary centers. Methods The medical records of 723 patients were retrospectively reviewed. The patients had locally advanced and nodal staged tumors and had undergone open radical nephroureterectomy (n = 388) or laparoscopic radical nephroureterectomy (n = 260) at five tertiary Korean institutions from January 2000 and December 2012. To control for heterogenic baseline differences between the two modalities, propensity score matching and subgroup analysis were conducted. Conditional survival analysis was also conducted to determine survival outcome and to overcome differences in follow-up duration between the groups. Results During the median 50.8-month follow up, 255 deaths occurred. In univariate analysis, significant factors affecting cancer-specific survival (e.g., age, history of bladder cancer, American Society of Anesthesiologists score, pathological N stage, and presence of lymphovascular invasion and carcinoma in situ) differed in each subsequent year. The cancer-specific survival between patients treated with open radical nephroureterectomy and laparoscopic radical nephroureterectomy was not different between patients with and without a history of bladder cancer. After adjusting baseline differences between the two groups by using propensity score matching, both groups still had no significant differences in cancer-specific survival. Conclusion The two surgical modalities showed no significant differences in the 5-year cancer-specific survival in patients with locally advanced urinary tract urothelial carcinoma.

Outcomes of laparoscopic, robotic and open nephroureterectomy with bladder cuff excision in patients with T3T4 upper urinary tract urothelial carcinoma: a multi-center retrospective study

“…However, the enrolled studies were published before August 2016, and a more recent meta-analysis showed comparable oncological outcomes between the two groups (7). Moreover, Kim et al analyzed the conditional CSS to minimize bias caused by inherent time data properties, and found no signi cant difference in conditional CSS between the two modalities (9). In our series, patients in the minimally invasive group had better OS and CSS than those in the open surgery group, even after adjusting for confounding factors.…”

The role of surgery for locally advanced urothelial cancers

“…Neoadjuvant therapy has been shown to down-stage primary tumors at a rate of 38% in eligible patients. However, unlike urothelial carcinomas of the bladder, many studies evaluating locally advanced urothelial carcinomas of the upper tracts report primary usage of platinum-based chemotherapy or immunotherapy in the adjuvant setting [2,17 ▪ ]. One study reported that approximately 47% of patients with locally advanced urothelial carcinomas of the upper tract received chemotherapy after RNU [17 ▪ ].…”

“…This study is unique as other recent studies comparing oncologic and surgical outcomes between open and minimally invasive approaches for RNU included a limited number of locally advanced upper tract tumors [20,21]. However, that study did not include patients who received neoadjuvant chemotherapy, preventing determination of the rate of downstaging by preoperative chemotherapy at the time of RNU [17 ▪ ].…”

“…In a large multicenter propensity-matched cohort of 723 patients with pT3-T4 or pathologically node-positive urothelial carcinoma study by Kim et al , there was no demonstrable difference in 5-year cancer-specific survival between open and laparoscopic RNU. The study reported hazard ratios for cancer-specific survival of 0.921 [95% confidence interval (CI) 0.682–1.244, P = 0.593] and 0.666 (95% CI 0.192–2.313, P = 0.523) at 1 and 5 years of follow-up [17 ▪ ]. This study is unique as other recent studies comparing oncologic and surgical outcomes between open and minimally invasive approaches for RNU included a limited number of locally advanced upper tract tumors [20,21].…”

“…However, unlike urothelial carcinomas of the bladder, many studies evaluating locally advanced urothelial carcinomas of the upper tracts report primary usage of platinum-based chemotherapy or immunotherapy in the adjuvant setting [2,17 ▪ ]. One study reported that approximately 47% of patients with locally advanced urothelial carcinomas of the upper tract received chemotherapy after RNU [17 ▪ ]. Given the rarity of upper tract urothelial carcinomas, there are limited recent studies evaluating the response rate after neoadjuvant chemotherapy in node-positive disease alone [18].…”