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Long-term oncologic outcomes of laparoscopic versus open radical nephroureterectomy for patients with T3N0M0 upper tract urothelial carcinoma: A multicenter cohort study with adjustment by propensity score matching

  • Keisuke Shigeta,
  • Eiji Kikuchi,
  • Takayuki Abe,
  • Masayuki Hagiwara,
  • Koichiro Ogihara,
  • Tadanori Anno,
  • Kota Umeda,
  • Yuto Baba,
  • Tansei Sanjo,
  • Kazunori Shojo,
  • Ryuichi Mizuno,
  • Mototsugu Oya

Publication: Annals of Surgical Oncology, October 2020

Background

This study aimed to investigate the long-term oncologic outcomes of laparoscopic radical nephroureterectomy (LRNU) and open radical nephroureterectomy (ORNU) for patients with clinical and pathologic T3N0M0 upper tract urothelial carcinoma (UTUC).

Methods

Among 375 UTUC patients who underwent radical nephroureterectomy, this study identified 144 pT3N0M0 patients as cohort 1 after propensity score (PS) matching. Among 399 UTUC patients, the study identified 110 cT3N0M0 patients as cohort 2 after PS matching. Oncologic outcomes such as intravesical recurrence-free survival (IVRFS) and cancer-specific survival (CSS) were assessed by multivariate Cox’s regression analysis.

Results

Cohort 1 of pT3N0M0 UTUC had 3-year CSS and IVRFS rates of 67.9 and 52.7%, respectively, in the LRNU group, which were significantly lower than in the ORNU group (81.4%, p = 0.039 and 71.6%, p = 0.046). The multivariate Cox’s regression analysis identified the type of surgical approach (LRNU vs. ORNU) as one of the independent prognostic factors for CSS (hazard rate [HR], 1.88, p = 0.043) and IVRFS (HR, 1.75, p = 0.049). Cohort 2 of cT3N0M0 UTUC had 3-year CSS and IVRFS rates of 48.5 and 41.4%, respectively, in the LRNU group, which were significantly lower than in the ORNU group (65.8%, p = 0.049 and 67.2%, p = 0.047), and the type of surgical approach (LRNU vs. ORNU) remained as one of the independent prognostic factors for CSS and IVRFS.

Conclusions

Based on clinical and pathologic T3N0M0 UTUC populations after PS adjustments, LRNU resulted in poorer CSS and IVRFS than ORNU.

Commentary by Dr. Pradere

Despite the development of endourological techniques for kidney sparing surgery in UTUC, radical nephro-ureterectom (RNU) remains the standard of care for intermediate- and high-risk patients. Nevertheless, RNU approach has been debated since a decade and particularly for high-risk UTUC. To date, the EAU guidelines recognize that laparoscopic (LRNU) approach is contraindicated for locally advanced UTUC, and a recent systematic review has also shown that LRNU is inferior to open RNU (ORNU) particularly when the bladder cuff is excised laparoscopically and when performed on locally advanced patients.

Shigeta et al. present in this multicenter Japanese study the long-term oncologic outcomes of laparoscopic versus open RNU specifically in pT3N0M0 patients.

Where most of the studies have assessed oncological outcomes based on pathological specimen, this interesting study has analyzed two different cohorts according to the clinical (cohort 1) or the pathological stage (cohort 2). To assess this specific population of T3, their primary endpoints were the intravesical recurrence free survival (RFS) and the cancer-specific survival (CSS). Both of the cohort had propensity score matching before the analysis.

It is important to note that patients who received a neoadjuvant systemic therapy were excluded. Moreover, all the procedures were performed similarly: an open iliac incision for the bladder cuff removal, no regional lymph node resection and no postoperative intravesical chemotherapy.

The first cohort of patients selected on the pathological stage included 144 patients. In multivariate analysis, LRNU and positive LVI were independent prognostic factors for cancer death (HR:1.88; p=0.043 and HR:3.24, p<0.001 respectively). And the 3 and 5 yr CSS rates were clearly lower in the LRNU group compared to ORNU (67.9% and 60.7% vs. 81.4 and 75.7%; p=0.039). Similarly, 3 and 5yr IVRFS were worse in the LRNU compared to the ORNU (52.7 and 38.7% vs. 71.6 and 64.3%; p=0.046)

The Second cohort selected on clinical preoperative CT scan (cT3), showed similar results compared to the first cohort. LRNU was an independent prognostic factor for cancer death (HR:1.92; p=0.047), had worse 3 and 5 yr CSS and IVRFS rates compared to ORNU (p=0.049 and p=0.047 respectively).

Conclusion:

ORNU had better results compared to LRNU in terms of 3- and 5-years CSS and IVRFS in this retrospective study. Despite the small sample size and the bias lead by its methodology, these results should continue to caution urologists on the approach for patients with T3 UTUC. Those who had a preoperative cT3 should probably be performed in an open fashion, and those who had pT3 at final pathology should benefit from close follow-up and administration of adjuvant chemotherapy.

To confirm the potential risk of laparoscopic RNU in terms of CSS and IVRFS prospective and larger cohort studies are expected.