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Robotic vs Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multicenter Propensity-Score Matched Pair "Tetrafecta" Analysis (ROBUUST Collaborative Group) – Beyond the Abstract

Radical nephroureterectomy (RNU) with bladder cuff excision is the standard of care for treatment of high-grade upper tract urothelial carcinoma (UTUC).1 While this procedure is traditionally performed via an open approach, minimally invasive techniques have been used more frequently in recent years. A population-based analysis recently reported an increasing trend in the utilization of robotic RNU from 29% in 2010 to 53% in 2016.2 Both laparoscopic and robotic techniques are associated with improved perioperative outcomes compared to open RNU.3 Nevertheless, robotic method provides multi-quadrant access and optimal exposure for lymph node dissection and intracorporeal bladder cuff excision during RNU, which has been one of the main challenges for the laparoscopic approach.

In this multicenter study, we compared the outcomes of robotic vs. laparoscopic RNU, using 2:1 nearest-neighbor propensity-score matching with respect to age, gender, race, body mass index, tumor size, and hydronephrosis. In addition, we introduced the concept of “tetrafecta” outcome, defined as (1) concomitant bladder cuff excision, (2) lymph node dissection, (3) no perioperative complications, and (4) negative surgical margins. Comparing 185 robotic and 91 laparoscopic RNUs, patients in the robotic group were more likely to undergo bladder cuff excision (82% vs. 64%) and had shorter length of stay (3.5 vs. 5 days). While overall postoperative complications were less with robotic vs, laparoscopic approach (25% vs. 43%), the high-grade complications (Clavien-Dindo grade ≥ 3) were comparable between the two groups. Using “tetrafecta” definition, laparoscopic approach was an independent negative predictor of the surgical outcomes following RNU (odds ratio: 0.09).

The results of this study suggest that, compared to laparoscopic technique, the robotic approach might facilitate the achievement of a “tetrafecta” outcome in UTUC patients undergoing RNU. Moreover, this novel outcome variable can be used as a proxy of “surgical quality” for minimally invasive RNU.

Written by: Alireza Ghoreifi,1 Alessandro Veccia,2 Riccardo Autorino,2 Hooman Djaladat1

  1. Institute of Urology, Norris Cancer Center, University of Southern California, Los Angeles, CA, USA
  2. Division of Urology, Virginia Commonwealth University Health System, Richmond, VA, USA

References:

  1. Rouprêt M, Babjuk M, Burger M, et al. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update. Eur Urol. 2021; 79:62-79.
  2. Kenigsberg AP, Smith W, Meng X, et al. Robotic Nephroureterectomy vs Laparoscopic Nephroureterectomy: Increased Utilization, Rates of Lymphadenectomy, Decreased Morbidity Robotically. J Endourol. 2021; 35:312-318.
  3. Lee H, Kim HJ, Lee SE, Hong SK, Byun SS. Comparison of oncological and perioperative outcomes of open, laparoscopic, and robotic nephroureterectomy approaches in patients with non-metastatic upper-tract urothelial carcinoma. PLoS One. 2019; 14:e0210401.

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