OBJECTIVES: To compare oncological outcomes of open (ORNU) and laparoscopic radical nephroureterectomy (LRNU) after controlling for preoperative patient-derived factors. PATIENTS AND METHODS: We evaluated a multi-institutional collaborative database composed of 3984 patients diagnosed with upper tract urothelial carcinoma (UTUC) treated with RNU between 2006 and 2018. To adjust for potential selection bias, propensity score matching adjusted for age, gender and American society Anesthesiology (ASA) score was performed with one ORNU patient matched to one LRNU patient. Uni- and multivariable Cox regression evaluating the risk of overall recurrence, cancer-specific mortality (CSM) and overall mortality (OM) in the overall population and after propensity matching were performed. RESULTS: In total, 3984 patients underwent RNU, of these 3227 (81%) patients were treated with ORNU and 757 (19%) patients with LRNU. Within a median follow-up of 62 months, 1276 recurrences, 844 CSMs and 1128 OMs were recorded. On multivariable analyses, the LRNU approach was associated with an increased risk of overall recurrence (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.03-1.54; P = 0.02), but on the other hand LRNU was associated with a protective effect on CSM (HR 0.74, 95% CI 0.56-0.98; P = 0.04). After propensity matching analyses adjusted for age, gender and ASA score, 757 patients treated with LRNU and 757 patients treated with ORNU were available for the analyses. On multivariable Cox regression, LRNU vs ORNU was not associated with any difference in overall recurrence (P = 0.08), CSM (P = 0.1) or OM (P = 0.9). CONCLUSION: Our present data suggest that even if the type of approach to RNU was associated with different survival outcomes considering the overall population, this difference vanished when adjusted for potential confounders in propensity matching analyses. Therefore, we found that LRNU is not inferior to the ORNU approach for the treatment of UTUC. ABBREVIATIONS: ASA: American Society of Anesthesiology; CIS: carcinoma in situ; CSM: cancer-specific mortality; HR: hazard ratio; IQR: interquartile range; LN: lymph node; LNI: lymph node invasion; LVI: lymphovascular invasion; OM: overall mortality; pT: pathological tumour stage; RCT: randomised controlled trial; (L)(O)RNU: (laparoscopic) (open) radical nephroureterectomy; UTUC: upper tract urothelial carcinoma.

Department of Medical and Surgical Specialties Radiological Science and Public Health University of Brescia Brescia Italy

Department of Urology 'Regina Elena' National Cancer Institute Rome Italy

Department of Urology and Oncologic Urology Wrocław Medical University Wroclaw Poland

Department of Urology Assistance Publique Hôpitaux De Paris CHU Mondor Faculté De Médecine Henri Mondor Hospital Créteil France

Department of Urology CHRU Tours Francois Rabelais University Tours France

Department of Urology CHU Bichat Paris France

Department of Urology European Institute of Oncology Milan Italy

Department of Urology La Paz University Hospital Madrid Spain

Department of Urology Luzerner Kantonsspital Luzern Switzerland

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

Department of Urology University Hospital Carl Gustav Carus Dresden Germany

Department of Urology University of Florence Unit of Oncologic Minimally Invasive Urology and Andrology Careggi Hospital Florence Italy

Department of Urology University of Texas Southwestern Medical Center Dallas TX USA

Department of Urology Urological Research Institute Vita Salute University San Raffaele Scientific Institute Milan Italy

Department of Urology Vienna General Hospital Medical University of Vienna Vienna Austria

Department of Urology Weill Cornell Medical College New York NY USA

Division of Urology Department of Special Surgery Jordan University Hospital the University of Jordan Amman Jordan

Division of Urology Department of Surgical Sciences University of Studies of Torino Turin Italy

Institute for Urology and Reproductive Health Sechenov University Moscow Russia

Karl Landsteiner Institute of Urology and Andrology Vienna Austria

Urology Assistance Publique Hôpitaux De Paris Sorbonne University Hopital Pitié Salpétrière Paris France

Urology Rennes University Hospital Rennes France

Urology Unit ASST Spedali Civili Brescia Italy

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