CONTEXT: Most series have suggested better perioperative outcomes of laparoscopic radical nephroureterectomy (RNU) over open RNU. However, the oncological safety of laparoscopic RNU remains controversial. OBJECTIVE: To systematically review all relevant literature comparing oncological outcomes of open versus laparoscopic RNU. EVIDENCE ACQUISITION: A systematic literature search using the Medline, Embase, and Cochrane databases and clinicaltrial.gov was performed in December 2014 and updated in August 2016. Randomised controlled trials (RCTs) and prospective or retrospective nonrandomised comparative studies comparing the oncological outcomes of any laparoscopic RNU with those of open RNU were included. The primary outcome was cancer-specific survival. The risk of bias (RoB) was assessed using Cochrane RoB tools. A narrative synthesis of the evidence is presented. EVIDENCE SYNTHESIS: Overall, 42 studies were included, which accounted for 7554 patients: 4925 in the open groups and 2629 in the laparoscopic groups. Most included studies were retrospective comparative series. Only one RCT was found. RoB and confounding were high in most studies. No study compared the oncological outcomes of robotic RNU with those of open RNU. Bladder cuff excision in laparoscopic groups was performed via an open approach in most studies, with only three studies reporting laparoscopic removal of the bladder cuff. Port-site metastasis rates ranged from 0% to 2.8%. No significant difference in oncological outcomes was reported in most series. However, three studies, including the only RCT, reported significantly poorer oncological outcomes in patients who underwent laparoscopic RNU, especially in the subgroups of patients with locally advanced (pT3/pT4) or high-grade upper tract urothelial carcinoma (UTUC), as well as in instances when the bladder cuff was excised laparoscopically. CONCLUSIONS: The current available evidence suggests that the oncological outcomes of laparoscopic RNU may be poorer than those of open RNU when bladder cuff is excised laparoscopically and in patients with locally advanced high-risk (pT3/pT4 and/or high-grade) UTUC. PATIENT SUMMARY: We reviewed the literature comparing the outcomes of two different surgical procedures for the treatment of upper tract urothelial carcinoma. Open radical nephroureterectomy is a surgical procedure in which the kidney is removed through a large incision in the abdomen, while in laparoscopic radical nephroureterectomy, the kidney is removed through a number of small incisions. Our findings suggest that the outcomes of laparoscopic radical nephroureterectomy may be poorer than those of open radical nephroureterectomy, particularly when the bladder cuff is also required to be removed. Laparoscopic radical nephroureterectomy may also be less effective in patients with locally advanced (pT3/pT4) or high-grade upper tract urothelial carcinomas.

Academic Urology Unit University of Aberdeen Aberdeen UK

Academic Urology Unit University of Aberdeen Aberdeen UK; Department of Urology Aberdeen Royal Infirmary Aberdeen UK

Department of Pathology Tenon Hospital Paris France

Department of Surgical Oncology Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital Amsterdam The Netherlands

Department of Urology Aberdeen Royal Infirmary Aberdeen UK

Department of Urology Caritas St Josef Medical Centre University of Regensburg Regensburg Germany

Department of Urology CHU Rennes Rennes France

Department of Urology Fundació Puigvert Universidad Autónoma de Barcelona Barcelona Spain

Department of Urology Fundación Instituto Valenciano de Oncología Valencia Spain

Department of Urology Hospital Motol 2nd Faculty of Medicine Charles University Praha Czech Republic

Department of Urology La Pitié Salpétrière Hospital Paris France

Department of Urology Medical University of Graz Graz Austria

Department of Urology Medical University of Vienna Vienna Austria

Department of Urology Radboud University Nijmegen Medical Centre Nijmegen The Netherlands

Department of Urology Royal Surrey County Hospital Guildford UK

Department of Urology University of Turin Turin Italy

Division of Gastroenterology Department of Medicine McMaster University Hamilton ON Canada

European Association of Urology Guidelines Office Brussels Belgium

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