title: Oncologic Outcomes Following Robot-Assisted Laparoscopic Nephroureterectomy with Bladder Cuff Excision for Upper Tract Urothelial Carcinoma.
abstract: OBJECTIVE
  Robot-assisted laparoscopic nephroureterectomy with bladder cuff excision is a minimally invasive alternative to open surgery for managing upper tract urothelial carcinoma. We report oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision.
  
  
  METHODS
  The records of the initial 65 patients who underwent robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma between 2008 and 2014 were reviewed from our institutional review board approved, prospectively maintained database. All patients underwent surgery with the single docking technique. Baseline demographic features, pathological variables and perioperative data were analyzed. Kaplan-Meier methodology was used for survival analysis. Cox proportional hazards regression was applied to determine the prognostic effect of different variables on survival.
  
  
  RESULTS
  Mean patient age was 69.1 years. Final pathological evaluation revealed pT2 stage or lower in 65% of patients, pT3 in 28.3% and pT4 in 6.7%. High grade pathological findings were present in 85% of patients, including 13.3% with concomitant carcinoma in situ and 30% with lymphovascular invasion. Median followup was 25.1 months (range 6 to 68.9). At 2 and 5 years overall survival was 86.9% and 62.6%, cancer specific survival was 92.9% and 69.5%, and recurrence-free survival was 65.3% and 57.1%, respectively. A total of 23 patients experienced disease recurrence. Bladder recurrence developed in 15 patients, 12 had isolated bladder recurrence and 8 had metastatic disease. On univariate analysis age greater than 70 years, preoperative hydronephrosis, nodal disease and concomitant carcinoma in situ were significantly associated with decreased recurrence-free survival (p=0.002, 0.04, 0.006 and 0.001, respectively). However, none was statistically significant on multivariate analysis. On univariate analysis impaired preoperative renal function (creatinine greater than 2 mg/dl) and lymphovascular invasion were associated with reduced cancer specific survival (p=0.03 and 0.01, respectively). However, only lymphovascular invasion was associated with decreased cancer specific survival on multivariate analysis (p=0.048).
  
  
  CONCLUSIONS
  Our reported data on oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma demonstrate satisfactory oncologic control at intermediate term followup. Long-term outcomes are required to assess true efficacy.
authors.affiliation: Urology Department, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.
authors.forename: Ahmed A
authors.initials: AA
authors.lastname: Aboumohamed
authors.affiliation: Urology Department, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.
authors.forename: Louis Spencer
authors.initials: LS
authors.lastname: Krane
authors.affiliation: Urology Department, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina. Electronic address: ahemal@wakehealth.edu.
authors.forename: Ashok K
authors.initials: AK
authors.lastname: Hemal
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods*; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000379:methods*; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*
keywords: carcinoma; mortality; nephrectomy; robotics; urinary bladder