Oncological Efficacy of Robotic Nephroureterectomy vs. Open and Laparoscopic Nephroureterectomy for Suspected Non-Metastatic UTUC—A Systematic Review and Meta-Analysis

SIMPLE SUMMARY: Upper tract urothelial cancer is an aggressive malignancy that requires prompt treatment in the form of removal of the kidney and ureter with a bladder cuff, especially for invasive disease. The ideal surgical technique should offer a complete cancer clearance, including the ability to remove lymph glands with a short recovery period. The three techniques currently available include open, laparoscopic, and robotic approaches. This review compares the three techniques both on cancer clearance and survival by analyzing the existing literature. We found the robotic technique to be similar or slightly superior to either the open or laparoscopic approach for overall survival, cancer-specific survival, lymph node removal rates, and the rates of risk for residual cancer (positive margins). However, the risk of recurrent tumours in the bladder was identified to be higher in robotic surgery compared to the open approach. The study determines that the robotic approach offers comparable outcomes to the open and laparoscopic approaches, which are well established but for which the overall quality of evidence has been poor. ABSTRACT: Introduction and Aims: The optimal approach for nephroureterectomy in patients with suspected UTUC remains a point of debate. In this review, we compare the oncological outcomes of robotic nephroureterectomy (RNU) with open (ONU) or laparoscopic nephroureterectomy (LNU). Methods: All randomized trials and observational studies comparing RNU with ONU and/or LNU for suspected non-metastatic UTUC are included in this review. The systematic review was performed in accordance with the Cochrane Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The primary outcome measures were overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and intravesical recurrence-free survival (IV-RFS). The secondary outcome measures were the lymph node dissection (LND) rates, positive margin rates, and the proportion of patients receiving bladder intravesical chemotherapy. Results: We identified 8172 references through our electronic searches and 8 studies through manual searching. A total of 15 studies met the inclusion criteria. The total number of patients in the review was 18,964. RNU had superior OS compared to LNU (HR: 0.81 (95% CI: 0.71, 0.93), p-0.002 (very low certainty)). RNU and ONU had similar OS (HR: 0.83 (95% CI: 0.52, 1.34), p-0.44 (very low certainty)). One study reported an independent association of RNU as a worse predictor of IV-RFS when compared to ONU (HR-1.73 (95% CI: 1.22, 2.45)). The LND rates were higher in the RNU cohort when compared to the LNU cohort (RR 1.24 (95% CI: 1.03, 1.51), p-0.03 (low certainty)). The positive margin rate was lower in the RNU cohort when compared to the ONU cohort (RR 0.29 (95% CI: 0.08, 0.86), p-0.03 (low certainty)). Conclusion: RNU offers comparable oncological efficacy to ONU, except for intravesical recurrence-free survival (IV-RFS). RNU has fewer positive surgical margin rates compared to ONU in well-balanced studies. RNU appears to outperform LNU for certain oncological parameters, such as OS and the proportion of patients who receive lymph node dissections. The quality of evidence comparing surgical techniques for UTUC has remained poor in the last decade.