Oncological outcomes of laparoscopic and open treatment (nephroureterectomy) for urothelial tumors of upper urinary tract

Giuseppe Lotrecchiano1, Pietro Saldutto1, Luigi Salzano1
  • 1 AORN "G. Rummo", U.O. Urologia (Benevento)

Objective

The open radical nephroureterectomy (ORN) with distal ureter and removal of a bladder cuff is considered the current standard of care for the treatment of carcinoma of the upper urinary tract (1). However, laparoscopy has been shown to be equally effective with lower perioperative morbidity (2). Laparoscopic nephroureterectomy (LRN), therefore it is emerging as a viable alternative minimally invasive. But the question remains on the safety and efficacy of oncological LRN and its equivalence to ORN.
Some authors have suggested that the dissection of the tumor and the high pressure of the gas that are established for the pneumoperitoneum during the LRN associated with a higher risk of bladder recurrence, local recurrence as well as metastases on Trocar sites (3).
The differential effect of LRN compared ORN on oncological outcomes after radical nephroureterectomy (RN) remains controversial. Although many recent studies report oncological results comparable between ORN and LRN in well selected patients (4-5 and 8), others reported a higher risk of intravesical recurrence of disease compared with LRN ORN (6-7).

We wanted to evaluate our clinical results between ORN and LRN, analyzing the data of 61 NUL performed between 2006 and 2016 and compared retrospectively with data from 37 NUO performed in the years 2002 to 2005 (it was pre-laparoscopy ).

Materials and Methods

We evaluated data collected retrospectively on 37 consecutive patients treated with ORN between 2002 and 2005 (it was pre-laparoscopy) and 61 patients undergoing LRN between 2006 and 2016.

ORN was performed according to the standard criteria, ie, the dissection of the kidney with the entire length of the ureter bladder and removal of a headset with a second short incision. Lymphadenectomy was not routinely performed unless the patient had no macroscopically or radiographically evident lymph nodes.
The laparoscopic technique has been performed with transperitoneal approach in 45 patients and with retroperitoneal approach 15. The excision of the bladder cuff has been carried out with open technique using the incision to remove the piece. In table 1, 2 and 3, the characteristics of patients and interventions
Patients were followed every 3 months for the first year, every 4 months for the second year, every 6 months starting from the third to fifth year and each year thereafter. The follow-up consisted of history, physical examination, routine blood tests, urine cytology, chest X-ray, CT uretrocistoscopica and Uro.
The average was 32 months follow-up in patients undergoing LRN and 52 months for those treated with ORN. We evaluated particularly cancer recurrence, the recurrence and survival site.

Results

We had local recurrence in 7 patients (11.4%) after LRN and in 2 (6.25%) after ORN.
2 patients undergoing LRN (5.5%) died from metastatic disease at 9 and 12 months, 3 patients underwent ORN (9.3%) died from metastases to 12, 16 and 23 months.
Was found bladder recurrence in 9 patients undergoing LRN and 4 after ORN.
The most frequent tumor recurrence sites were: local recurrence (7 LRN-2 ORN), 1 recurrence of laparoscopic port, 3 recurrences in the regional lymph nodes (6 LRN, 1 ORN), bladder (LRN 9, 4 ORN) .There were no significant differences in recurrence and even the survival rates at 1 and 3 years old are not very different results between the two techniques.

Some researchers have suggested that the manipulation of the tumor during the LRN can lead to a migration of tumor cells with the possible plant to secondary sites, and in the bladder, due to the high gas pressure required for the laparoscopic procedure (3).
Moreover, it was also reported as a possible concern with the LRN of tumoral cells of the plant in Trocar sites (3). However, these potential risks of LRN are controversial and have not gotten feedback in the various works carried out (11).

In agreement with many previous studies, we found no significant difference in recurrence, recurrence in the bladder, and in the specific cause of death from the disease among patients treated with ORN and those with LRN (4-5- 8-9). Also as in other studies (5, 8 and 9), we found no significant association between surgical approach and death due to illness.

Discussions

Some researchers have suggested that the manipulation of the tumor during the LRN can lead to a migration of tumor cells with the possible plant to secondary sites, and in the bladder, due to the high gas pressure required for the laparoscopic procedure (3).
Moreover, it was also reported as a possible concern with the LRN of tumoral cells of the plant in Trocar sites (3). However, these potential risks of LRN are controversial and have not gotten feedback in the various works carried out (11).

In agreement with many previous studies, we found no significant difference in recurrence, recurrence in the bladder, and in the specific cause of death from the disease among patients treated with ORN and those with LRN (4-5- 8-9). Also as in other studies (5, 8 and 9), we found no significant association between surgical approach and death due to illness.

Conclusion

The grade and stage of the cancer affect the incidence of metastatic disease, and is a poor prognostic factor in the primitive location of the disease (pelvis-ureter-both), rather than the surgical technique used.
There is no evidence so that the cancer control is compromised in patients treated with LRN rather than by ORN.

Reference

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