In this context, the Junior ERUS/YAU Working Group provides important multicenter data evaluating robot-assisted RNU in 191 patients with locally advanced UTUC across nine high-volume centers (2019–2023). This is among the largest series to specifically examine outcomes in this subgroup, addressing a notable evidence gap.
Key findings:
- Survival outcomes: At a median follow-up of 19 months, the estimated 3-year recurrence-free survival (RFS) and cancer-specific survival (CSS) were 69.8% and 88.4%, respectively. These results compare favorably with historical open cohorts and support the oncologic feasibility of the robotic approach in expert hands.
- Bladder cuff management: Bladder recurrence occurred in 16.4% of patients. On multivariate analysis, extravesical cuff excision was an independent predictor of bladder recurrence, while intravesical excision conferred superior local control. Importantly, the surgical approach (robotic vs open) was not associated with differences in recurrence or progression, emphasizing that surgical technique rather than modality drives oncologic safety.
- Lymph node dissection: LND was performed in 55% of patients. Pathologic nodal involvement was detected in over one-quarter of the cohort and was the strongest predictor of disease progression. Despite this, LND performance was heterogeneous across centers, reflecting ongoing variability in practice.
- Systemic therapy: Adjuvant chemotherapy or immunotherapy was protective against recurrence and progression, consistent with current guideline recommendations.
- Perioperative outcomes: Robotic RNU demonstrated acceptable operative times, low blood loss, and a major complication rate of only 2.6%, reinforcing the perioperative safety profile of robotic surgery.
This study provides further reassurance that robot-assisted RNU can achieve satisfactory oncologic outcomes even in locally advanced UTUC. The oncologic safety of robotics appears comparable to open surgery when bladder cuff excision and nodal dissection are performed appropriately. The finding that extravesical cuff management independently increases recurrence risk highlights the importance of standardized intravesical excision, irrespective of approach.
The relatively low adoption of postoperative intravesical chemotherapy (20%) and heterogeneous use of LND underscore gaps in real-world practice. As robotic surgery enables more reproducible intracorporeal bladder cuff excision and may facilitate comprehensive template-based LND, its role could be central in standardizing oncologic quality in RNU.
Limitations include the retrospective design, modest follow-up, and performance of surgery by highly experienced robotic surgeons, which may limit generalizability. Nonetheless, the multicenter nature, large cohort size, and focus on high-risk disease represent significant strengths.
Conclusion:
This international series suggests that in experienced centers, robotic RNU offers oncologic outcomes equivalent to open surgery in patients with locally advanced UTUC. Optimal outcomes depend less on surgical platform and more on adherence to oncologic principles—complete bladder cuff excision, systematic lymphadenectomy, and integration of perioperative systemic therapy. These data support the continued integration of robotics into the management of advanced UTUC and provide a foundation for prospective studies to validate long-term outcomes.
Written by: Fabrizio Di Maida, MD, FEBU, Urologist, Unit of Urology and Andrology, Careggi University Hospital; Member, EAU Young Academic Urologists (YAU) Robotic Surgery Working Group, Florence, Italy
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