title: Laparoscopic radical nephroureterectomy: results of an international multicenter study.
abstract: OBJECTIVE
  To report a multicenter analysis after laparoscopic radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma.
  
  
  METHODS
  A total of 116 patients (72 males; mean age 68 years) underwent laparoscopic radical nephroureterectomy at five international institutions: 51 transperitoneally, 65 retroperitoneally. Location of the primary tumor was pelvicalyceal in 70 patients (60%), ureteral in 27 (23%), and multifocal in 19 (17%). In 18 patients (15%), transurethral resection was performed for concomitant bladder tumor. The median follow-up time was 25 months (range 3-93). A minimum follow-up of 1 and 2 years was available in 77 and 41 patients, respectively.
  
  
  RESULTS
  Five patients (4%) were converted to open surgery. The specimen was extracted intact in all 116 patients: using an Endocatch bag in 78 patients, a Lapsac in 5, and manually in 33. Pathologic staging was pTis in 5 (4%), pTa in 41 patients (35%), pT1 in 31 (26%), pT2 in 18 (15%), pT3 in 16 (13%), and pT4 in 5 (4%). Pathological grade was grade I in 26 patients (23%), grade II in 41 (35%), grade III in 34 (29%) and grade IV in 15 (12%). Histopathology revealed a positive surgical margin in five patients (4.5%): renal hilum (one), periureteral soft tissue (two), distal edge of the ureter/ bladder cuff (two). Local recurrence was noted in two patients (1.7%). Bladder recurrence was noted in 28 patients (24%) with a mean time to recurrence of 13.9+/-11.5 months. Distant metastases occurred in 11 patients (9%): lung (5), liver (3), bones (2), adrenal (1); mean time to metastasis was 13 months. Overall, 23 patients (20%) died. One-year and 2-year cancer-specific survival was 92% and 87%, respectively. Two-year cancer-specific survival according to pathologic stage was 89% for patients with pT1 disease, 86% for pT2, 77% for pT3, and 0% for pT4 (p=0.0001). Two-year survival according to pathologic grade was 88% for grade I, 90% for grade II, 80% for grade III, and 90% for grade IV (p>0.05).
  
  
  CONCLUSIONS
  Laparoscopic radical nephroureterectomy appears to be an effective minimally invasive treatment for select patients with upper tract transitional cell carcinoma. Although the 2-year survival data reported herein are encouraging, longer follow-up is needed before laparoscopy can be considered as a standard treatment.
authors.affiliation: Cleveland Clinic Urological Institute, Cleveland, OH, USA.
authors.forename: Hazem Abou
authors.initials: HA
authors.lastname: El Fettouh
authors.forename: Jens J
authors.initials: JJ
authors.lastname: Rassweiler
authors.forename: Michael
authors.initials: M
authors.lastname: Schulze
authors.forename: Laurent
authors.initials: L
authors.lastname: Salomon
authors.forename: James
authors.initials: J
authors.lastname: Allan
authors.forename: Sanjay
authors.initials: S
authors.lastname: Ramakumar
authors.forename: Thomas
authors.initials: T
authors.lastname: Jarrett
authors.forename: Claude C
authors.initials: CC
authors.lastname: Abbou
authors.forename: David A
authors.initials: DA
authors.lastname: Tolley
authors.forename: Louis R
authors.initials: LR
authors.lastname: Kavoussi
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D009364:Neoplasm Recurrence, Local; D009378:Neoplasms, Multiple Primary / Q000473:pathology / Q000601:surgery*; D009392:Nephrectomy; D016019:Survival Analysis; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery; D014571:Urologic Neoplasms / Q000473:pathology / Q000601:surgery*