Arieh L. Shalhav Is There a Risk in Robotic Nephroureterectomy?

Arieh L. Shalhav Is There a Risk in Robotic Nephroureterectomy?

80 patients LNU (n = 40) or ONU (n = 40) CSS (p = 0.2), BRFS (p = 0.86), MFS (p = 0.12) similar for the entire cohort Subgroups of pt3 UTUC and high-grade tumors better CSS and MFS for ONU compared LNU p = 0.04 and p = 0.004, respectively, for pt3 p = 0.01 and p = 0.01, respectively, for high-grade disease

Meta analysis 2012, 21 studies published before 2011 ONU 3093 LNU 1235 Better 5Y CSS for LNU (by 9% av) Same complication rate and periop mortality Same 5Y OS, RFS

N 371 1992-2012 ONU LNU 271 100 3Y IVRFS 59.9 61.7 p 0.267 5Y OS 75.2 59.1 p 0.027 5Y CSS 80.2 66.1 p 0.015 MV analysis only PT3/4 worse PT3/4 OS HR 2.59 p=0.01 PT3/4 CSS HR 2.50 p= 0.005

Published 2017 5 medical centers 2000-2012 ONU LNU 906 615 5Y IVRFS 51% 57.8 0.010 5Y CSS 76.4% 80.4 0.032 5Y OS 71.4% 75.8 0.026 pt3/4 5Y IVRFS (MVA) 54.1 62.9 0.038 5Y CSS 56.9% 64.3 0.022 5Y OS 53.1 60.4 0.018

Meta Analysis; 42 studies till 2016, 7554 pts ONU 4925 LNU2629

Meta Analysis; 42 studies till 2016, 7554 pts ONU 4925 LNU2629 Port site mets Peritoneal carcinomatosis none Oncologic outcomes 6/2629 (0.02%)LNU 39/42 studies equal 3 studies poorer for LNU in T3/4 LND rarely performed, equally distributed between ONU and LNU one study; higher node yield for ONU Bladder cuff done open in 35 LNU, (3 pure lap, 4 endoscopic) 2 studies no bladder cuff in some pts LNU=ONU

Meta Analysis; 42 studies till 2016, 7554 pts ONU 4925 LNU2629 Pathological findings Surgical Margins same <20% Positive Nodes same <17% PT3-4 ratio same Less Primary Ureteral TCC in LNU patients

Meta Analysis; 42 studies till 2016, 7554 pts ONU 4925 LNU2629 Combined Vs Open RNU (16 studies) 1/16 studies poorer oncologic outcome for LNU (The Korean study) 1/16 better 5y CSS for LNU (French study) Pure Lap vs Open RNU 1/3 RCT poorer oncologic outcome for T3/HG LNU (The Italian study) 1/3 poorer RFS for open 1/3 no difference

Meta Analysis; 42 studies till 2016, 7554 pts ONU 4925 LNU2629 Unspecified/heterogenous lap vs open RNU 1/19 trend towards poorer RFS for LNU 1/19 trend towards poorer CSS and RFS for LNU 1/19 BRFS poor for Hand Assisted lap done endoscopically MVA Lap RNU w endoscopic bladder cuff vs open RNU 0/4 showed oncologic inferiority Subgroup of Locally advanced dis (T3/4 and high grade) 4/10 better CSS, OS, RFS for ONU No comparison of retroperitoneal recurrence performed

Meta Analysis; 42 studies till 2016, 7554 pts ONU 4925 LNU2629 Conclusions Oncologic equivalence in most studies However can not be established when the bladder cuff is taken laparoscopically or for T3/4 and HG Assumption Technical difficulty of lap bladder cuff management

Meta analysis of articles published until 2017 1630 patients 792 RANU 838 LNU Mean operative time 298 251 min, P = 0.03 Median node count 5.5 1.0 Positive surgical margins 1.69% 7.06%, P = 0.18 bladder recurrence 24.6% 36.89%, P = 0.09 Distant metastases 27.50% 17.50%, P = 0.29 Disease-specific mortality 7.5% 12.5%, P = 0.46 Perioperative mortality 0.14% 1.32%, P = 0.03 Overall complication rate 12.5% 18.8% P < 0.001

My Guiding Principles for NephroUreterectomy: For the older, frail patient -Is this more a palliative or curative procedure? Is life expectancy long enough to warry about ureteral recurrence? Are positive lymph nodes going to change treatment plan -There are higher surgical risks with 1. Total NephroUreterectomy with bladder cuff vs Nephrectomy 2. Complete suprahilar to pelvic LND vs no LND? In selected pts with no distal ureteral tumor nephrectomy only is appropriate

820 NxUx Pts Intravesical Extravesical Endoscopic 5Y RFS 46% 36% 30% If you do a bladder cuff, do it right! RNU, LNU,ONU

My Guiding Principles for NephroUreterectomy: Technique - The nephrectomy is harder in most cases - First clip the ureter - Always take a classic, visual bladder cuff - Always 2 layers bladder closure and assess for leak intraop with 240cc bladder irrigation -Low threshold to undock, reposition, redock, add trocars, add time. or convert Do not struggle!

2. Lymph node dissection

3. Distal ureter dissection and bladder cuff excision

Thank You

Case Presentation 68 years old male Abdominal pain PMH: Type 2 DM, Hypertension. Social: former smoker. Performed in OSH: CT : 2.3 cm enhancing lobulated mass within left renal pelvis Cystoscopy + Ureteroscopic biopsy: bladder biopsy negative, renal pelvis mass consistent with high grade urothelial carcinoma. Chest X-ray negative.

CT Abdomen and Pelvis 03/27/2018

1. Kidney dissection and clip ureter

Pathology Specimens Left kidney, ureter and bladder cuff. Left parahilar and para-aortic lymph nodes (11) Tumor size: 4.2 x 3.6 x 2.0 cm High-grade papillary urothelial carcinoma, invasive into lamina propria. Surgical margins: negative Regional lymph nodes: no tumor present (0/11) pt1, N0

Post operative management - In a chair and light dinner eve of surgery - Drain 24-48hours - DC Home POD 1 or2 - DC Foley POD 5 - Cystogram only if questionable closure

Post operative management - In a chair and light dinner eve of surgery - Drain 24-48hours - DC Home POD 1 or2 - DC Foley POD 5

https://www.ecrt.org/upload/pdf/crt-2017-417.pdf

https://link.springer.com/content/pdf /10.1007%2Fs00345-015-1712-3.pdf