Robotic versus other nephroureterectomy techniques: a systematic review and meta-analysis of over 87,000 cases

Abstract

Purpose To perform a systematic review and meta-analysis of the literature inherent robotic nephroureterectomy (RNU) and to compare its outcomes with those of other nephroureterectomy (NU) techniques. Methods A systematic literature search was performed up to April 2019 using PubMed, Embase®, and Web of Science. The Preferred Reporting Items for Systematic Review and Meta-analysis Statement was followed for study selection. The following data were extracted for each study: baseline features, surgical outcomes, oncological outcomes, and survival outcomes. Stata® 15.0 was used for statistical analysis. Results Literature search identified 80 studies eligible for the meta-analysis and overall 87,291 patients were included in the analysis: open NU (ONU; n = 45,601), hand-assisted laparoscopic NU (HALNU; n = 442), laparoscopic NU (LNU n = 31,093), and RNU (n = 10,155). RNU was more likely to be performed in those patients with multifocal tumor location (proportion: 0.19; 95% CI 0.14, 0.24) and high-grade disease (proportion: 0.70; 95% CI 0.53, 0.68). The lowest EBL was recorded in the RNU group (weighted mean (WM) 163.31 mL; 95% CI 88.94, 237.68), whereas the highest was in the ONU group (414.99 mL; 95% CI 378.52, 451.46). Operative time was shorter for ONU (224.98 mL; 95% CI 212.26, 237.69). RNU had lower rate of intraoperative complications (0.02; 95% CI 0.01, 0.05). ONU showed higher odds of transfusions (0.20; 95% CI 0.15, 0.25). LOS was statistically significantly shorter for the RNU group (5.35 days; 95% CI 4.97, 5.82). HALNU seemed to present lower risk of PSM (0.02; 95% CI − 0.01, 0.05), and lower risk of recurrence (0.22; 95% CI 0.15, 0.30), metastasis (0.07; 95% CI 0.05, 0.10), and cancer-related death (0.03; 95% CI 0.01, 0.06). ONU showed the lowest 5 years cancer specific survival (proportion: 0.77; 95% CI 0.74, 0.80). No correlation was found between the surgical technique and recurrence-free and cancer-specific survival. Conclusions Evidence regarding RNU for the treatment of UTUC is increasing but it remains quite sparse and of low quality. Despite this, RNU seems to be safe, and to offer the advantages of a minimally invasive approach without impairing the oncological outcomes. Nevertheless, ONU, HALNU, and LNU still represent a valid, and commonly used surgical treatment option. As RNU becomes more popular, and concerns related to its use remain, the best surgical technique for NU remains to be determined. Keywords Open radical nephroureterectomy • Hand-assisted radical nephroureterectomy • Laparoscopic radical nephroureterectomy • Robotic radical nephroureterectomy • Upper tract urothelial carcinoma Electronic supplementary material The online version of this article (

Editorial Comment to “Evaluating the Oncological Outcomes of Pure Laparoscopic Radical Nephroureterectomy Performed for Upper Tract Urothelial Carcinoma Patients: A Multicenter Cohort Study Adjusted by Propensity Score Matching”

“…To the best of my knowledge, there have been no reports of an increased risk of atypical recurrence associated with RRNU. 7 However, as was shown in the present study, we should note that atypical recurrence may occur, especially during the learning curve of RRNU, and steps should be taken to not compromise the oncological outcomes of patients.…”

Role of the Laparoscopic Approach for Complex Urologic Surgery in the Era of Robotics

“…When comparing series reporting laparoscopic and robotic radical nephroureterectomy with bladder cuff excision, no significant differences were observed for the operative time and major complications rate or oncologic outcomes (Table 3). On the other hand, the open approach for radical nephroureterectomy has shown lower 5-year cancer-specific survival as compared with minimally invasive techniques [30]. Primary T1 high-grade bladder tumors treated conservatively with transurethral resection and BCG protocols have a 64.9% rate of recurrence and 33% rate of progression during the first 36 months of follow-up [39].…”

Safety and feasibility of early single‐dose mitomycin C bladder instillation after robot‐assisted radical nephroureterectomy

“…Reported intermediate oncological outcome data with this approach were satisfactory [22]. Regarding surgical safety, a very recent systematic review compared various RNU techniques including resection of a bladder cuff [23]. The series included >80 000 patients of which >10 000 underwent RARNU.…”