黃烱焜、黃逸修^1,2*、魏子鈞^1,2、黃奕燊^1,2、范玉華^1,2、林志杰^1,2、林子平^1,2、鍾孝仁^1,2、

郭俊逸^1,2、吳宏豪^1,2、盧星華^1,2、張延驊^1,2、林登龍^1,2、黃志賢^1,2

臺北榮民總醫院 泌尿部^1,2

國立陽明大學醫學院泌尿學科及書田泌尿科學研究中心^1,2

Chiung-Kun Huang¹, Eric Y.H. Huang^1,2*, Tzu-Chun Wei^1,2, Yi-Shen Huang^1,2,
Yu-Hua Fan^1,2,Chi-Chieh Lin^1,2, Tzu-Ping Lin^1,2, Hsiao-Jen Chung^1,2,
Junne-Yih Kuo^1,2, Howard H.H. Wu^1,2, Shing-Hwa Lu^1,2, Yen-Hwa Chang^1,2,
Alex T.L. Lin^1,2, William J.S. Huang^1,2

Department of Urology, Taipei Veterans General Hospital^1,2

Department of Urology, School of Medicine and Shu-Tien Urological Institute,

 National Yang-Ming University, Taipei, Taiwan^1,2

 

Purpose: Radical nephroureterectomy (RNU) is the standard for upper urinary tract urothelial carcinoma (UTUC). However, it is still controversial regarding open nephroureterectomy (ORNU) or minimally invasive surgery (MIS) including laparoscopic (LRNU) or robotic nephroureterectomy (RANU) in the treatment of locally advanced UTUC (T3/T4). We aim to compare the oncological outcomes between ORNU and MIS in locally advanced UTUC patients.

Materials and Methods: We retrospectively analyzed the patients who underwent ORNU, LRNU, and RANU between 2004 and 2017 in our institute. They have been pathologically staged as T3 or T4 postoperatively. Regional lymphadenectomy was performed in patients with suspicious lymph nodes on preoperative images or with lymphadenopathies detected intraoperatively. Extended lymphadenectomy was not routinely performed. Statistical analysis of demographic data was performed using ANOVA or chi-squared test. The Kaplan–Meier method and log-rank test were used to estimate and compare the survival curves. Factors associated with survival outcomes were evaluated using univariable and multivariable Cox proportional hazard models.

Results: In our series, 58 and 98 patients underwent ORNU (T3/T4, n= 44/14) and MIS (T3/T4, n=85/13), respectively. Post-operative parameters including tumor stage, presence of lymphovascular invasion (LVI), concomitant carcinoma in situ (CIS), surgical margin, and post-operative adjuvant chemotherapy (ACH) were similar in two groups (ORNU and MIS). The MIS group was older (ORNU vs. MIS mean 72.0±11.0 vs. 75.5±8.5 years, p= 0.028) and higher in BMI (ORNU vs. MIS mean 22.4±3.9 vs. 24.0±3.9 kg/m2 , p= 0.017). The ORNU group showed a higher percentage of pre-operative suspicious lympadenopathy (ORNU vs. MIS 39.3% vs. 22.2%, p= 0.032);(ORNU T3/T4:n=15/9, MIS T3/T4: n=17/5) or parenchymal/extracapsular tumor invasion (ORNU vs. MIS 37.7% vs 15.2%, p= 0.002) (ORNU T3/T4: n= 12/11, MIS T3/T4: n=10/5) detected[EYH1]  by preoperative CT or MRI. The mean follow-up duration was 34.8±3.6 months (open vs. MIS 33.8±2.9 vs. 35.5±4.3 months[EYH2] ). The survival outcomes including overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) showed no significant differences between ORNU and MIS (OS: p= 0.139, CSS: p= 0.096 RFS: p= 0.104).

Conclusions: For patients who had locally advanced UTUC, ORNU had a higher percentage of pre-operative suspicious lymphadenopathy or parenchymal/extracapsular tumor invasion. LRNU group was older and higher in BMI. There were no differences in the overall survival, cancer-specific survival, or recurrence free survival between ORNU and MIS.

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