Robot-assisted radical nephroureterectomy for locally advanced upper tract urothelial carcinoma: a multicenter study by the Junior ERUS/YAU Working Group on Robot-assisted Surgery

Introduction: Aim of the study was investigate outcomes of patients affected by locally advanced (pT3-pT4 and/or pN+) upper tract urothelial carcinoma (UTUC) and treated with robot-assisted radical nephroureterectomy (RNU). Materials and methods: Clinical and surgical data of newly-diagnosed UTUC patients referring to 9 high-volume centres from January 2019 to March 2023 undergoing RNU were collected. Results: 191 patients showed locally advanced disease. Da Vinci and Hugo RAS ™ System were employed in 95.8 % and 4.2 % of cases, respectively. Bladder cuff removal was carried out in 161 (84.3 %) patients, by using either an intravesical and extravesical approach in 50 (31.1 %) and 111 (68.9 %) respectively. Open and robotic approaches for bladder cuff removal were preferred in 107 (66.5 %) and 54 (33.5 %) patients, respectively. Lymph node dissection was performed in 55 % of patients. Median follow up was 19 (IQR 10–23) months and 31 (16.4 %) patients experienced bladder recurrence. On multivariate analysis, in those patients receiving RNU and bladder cuff removal, the approach for bladder cuff management (extravesical vs intravesical) was the only independent predictor of bladder recurrence (hazard ratio [HR]: 1.34; 95 % confidence interval [CI] 1.12–2.11; p = 0.03). Surgical approach for bladder cuff management (open vs robot) was not independently associated with bladder recurrence or tumor progression (both p > 0.05) Conclusions: In experienced hands, the robotic approach showed satisfactory survival outcomes also for the surgical treatment of pathological locally advanced UTUC. Extravesical approach for bladder cuff management may be burdened by a higher risk for bladder recurrence in locally advanced disease.