FOIU 2018: Is There a Risk in Robotic Nephro-ureterctomy?

Tel-Aviv, Israel ( Dr. Shalhav gave an excellent talk on the different surgical modalities of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). He began by discussing some papers comparing open and laparoscopic RNU, that have been published in recent years. The first paper discussed compared 40 laparoscopic to 40 open RNU, demonstrating that only subgroups of Pt3 UTUC and high-grade tumors have better cancer specific survival (CSS) and metastasis free survival (MFS) in open RNU (ORNU) compared to laparoscopic RNU (LRNU). [1]

Another paper discussed is a systematic review of LRNU vs. ORNU [2], analyzing 21 studies published before 2011, with 3093 and 1235 patients undergoing ORNU and LRNU, respectively. Conversely, this study demonstrated better 5-year CSS for the LRNU patients by a mean of 9%. The complication rate, perioperative mortality, 5-year overall survival (OS) and recurrence free survival (RFS) were similar. Another more recent study, published in 2017, included 5 medical centers in Korea, showed an advantaged for LRNU. [3]

Lastly, a meta-analysis including 42 studies until 2016 comparing 4925 ORNU to 2629 LRNU patients. [4] When assessing the combined approach of LRNU for the kidney and open incision for the bladder cuff to ORNU, 1/16 of the studies showed poorer oncologic outcomes for LRNU, while 1/16 studies had better 5-year CSS. When comparing pure LRNU to ORNU, 1/3 of trials demonstrated poorer oncologic outcomes for Pt3/ high grade LRNU, 1/3 had no difference, and 1/3 had poorer RFS for ORNU. In conclusion, there was oncologic equivalence in most studies.

Dr. Shalhav continued and discussed his guiding principles for RNU in general:
  1. For the older, more frail patients it is important to distinguish between a curative and palliative procedure.
  2. We need to understand if life expectancy is long enough to worry about ureteral recurrence.
  3. Do we need to perform a lymph node dissection as well, and is that going to change prognosis?
  4. In selected patients with no distal ureteral tumor, nephrectomy only is appropriate
Dr. Shalhave moved on to give his guiding principles for robotic RNU:
  1. The nephrectomy is usually harder than it would seem
  2. The ureter must be clipped as fast as possible
  3. A full bladder cuff must be always excised
  4. It is important to close the bladder with 2 layers and assess for leak.
  5. There should always be a low threshold for undocking, repositioning, redocking, adding trocars, add additional time, or convert to an open procedure
  6. Most importantly, make sure you do not struggle.
Presented By: Arieh L. Shalhav, The University of Chicago, Chicago, IL, USA

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 FOIU 4th Friends of Israel Urological Symposium, July 3-5. 2018, Tel-Aviv, Israel

[1] Simone G. et al. Laparoscopic vs. open nephroureterectomy: perioperative and oncologic outcomes from a randomized prospective study. Eur Urology 56 (2009) 520-526
[2] Ni S. et al. Laparoscopic versus open nephroureterectomy for the treatment of upper urinary tract urothelial carcinoma: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2012 Jun;61(6):1142-53. doi: 10.1016/j.eururo.2012.02.019. Epub 2012 Feb 15.
[3] Ileon Kim. Et al. The comparison of oncologic outcomes between open and laparoscopic radical nephroureterectomy for the treatment of upper urothelial carcinoma: a Korean multicenter collaborative study. Cancer Res Treat. 2018 Apr 24. doi: 10.4143/crt.2017.417. [Epub ahead of print]
[4] Peyronnet B. et al. Oncologic outcomes of laparoscopic versus open radical nephroureterectomy for upper tract urothelial carcinoma: an European association of urology guidelines systematic review. Eur Urol Focus 2017