Open, laparoscopic, and robotic radical nephroureterectomy for upper tract urothelial carcinoma: Comparing outcomes and the tetrafecta as a composite marker of surgery quality

Abstract

Introduction: The purpose of this study was to compare surgical outcomes and costs between robotic radical nephroureterectomy (RNU), laparoscopic radical nephroureterectomy (LNU), and open radical nephroureterectomy (ONU), and to assess the relevance of the tetrafecta as a composite outcome on survival parameters after nephroureterectomy (NU). Methods: Operative and oncologic followup data was retrospectively collected on patients who underwent NU from 2006-2022 at our institution. The tetrafecta was defined as a true bladder cuff, lymph node dissection, negative surgical margins, and no postoperative complications. Cox proportional hazards regression was used to assess the impact of surgical approach on survival outcomes. Results: A total of 248 patients were included in the analysis (145 RNU, 61 LNU, and 42 ONU). The complication rate differed by approach and was lowest in RNU (p<0.01). Cancer-specific survival (CSS) differed between ONU and RNU patients, with ONU patients 2.51 times as likely to die from their cancer. Retroperitoneal recurrence-free survival (RPFS) differed between ONU and RNU patients, with ONU patients 7.22 times more likely to experience a retroperitoneal recurrence (p=0.0013). Variable surgical costs were lower in LNU compared to ONU (p=0.028) and direct inpatient hospital costs were lowest with RNU (p<0.01). Eighty-one patients met criteria for the tetrafecta. RNU patients were more likely to achieve the tetrafecta compared to LNU (p<0.01) and ONU (p<0.01) patients. No differences in survival parameters existed between patients who did and did not achieve the tetrafecta. Conclusions: Most oncologic outcomes after NU do not differ by approach on long-term followup; however, CSS and RPFS appear to differ between RNU and ONU. ONU has traditionally been considered the approach with the lowest cost; however, our analysis demonstrates both RNU and LNU require lower costs than ONU, depending on the cost parameter analyzed. Among all approaches, the tetrafecta is best achieved with RNU.