Rajan Karthik, Khalifa Ahmad, Geraghty Robert, Parmar Kalpesh, KandaSwamy Gokul, Gómez Rivas Juan, Somani Bhaskar, Rai Bhavan Prasad
Department of Urology, Freeman Hospital, Newcastle NE7 7PJ, UK.
Department of Urology, Morriston Hospital, Swansea SA6 6NL, UK.
Cancers (Basel). 2023 Oct 10;15(20):4926. doi: 10.3390/cancers15204926.
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).
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.
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), -0.002 (very low certainty)). RNU and ONU had similar OS (HR: 0.83 (95% CI: 0.52, 1.34), -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), -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), -0.03 (low certainty)).
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.
对于疑似上尿路尿路上皮癌（UTUC）患者，肾输尿管切除术的最佳方法仍是一个有争议的问题。在本综述中，我们比较了机器人辅助肾输尿管切除术（RNU）与开放肾输尿管切除术（ONU）或腹腔镜肾输尿管切除术（LNU）的肿瘤学结局。
本综述纳入了所有比较RNU与ONU和/或LNU治疗疑似非转移性UTUC的随机试验和观察性研究。系统评价按照Cochrane指南和系统评价与Meta分析的首选报告项目（PRISMA）进行。主要结局指标为总生存期（OS）、癌症特异性生存期（CSS）、无病生存期（DFS）和膀胱内无复发生存期（IV-RFS）。次要结局指标为淋巴结清扫（LND）率、切缘阳性率以及接受膀胱内化疗的患者比例。
通过电子检索我们识别出8172篇参考文献，通过手工检索识别出8项研究。共有15项研究符合纳入标准。本综述中的患者总数为18964例。与LNU相比，RNU的OS更佳（风险比[HR]：0.81（95%置信区间[CI]：0.71，0.93），-0.002（极低确定性））。RNU和ONU的OS相似（HR：0.83（95%CI：0.52，1.34），-0.44（极低确定性））。一项研究报告称，与ONU相比，RNU是IV-RFS更差的预测指标（HR-1.73（95%CI：1.22，2.45））。与LNU队列相比，RNU队列的LND率更高（相对危险度[RR]1.24（95%CI：1.03，1.51），-0.03（低确定性））。与ONU队列相比，RNU队列的切缘阳性率更低（RR 0.29（95%CI：0.08，0.86），-0.03（低确定性））。
除膀胱内无复发生存期（IV-RFS）外，RNU与ONU的肿瘤学疗效相当。在平衡良好的研究中，RNU的手术切缘阳性率低于ONU。在某些肿瘤学参数方面，如OS和接受淋巴结清扫的患者比例，RNU似乎优于LNU。在过去十年中，比较UTUC手术技术的证据质量一直较差。
