Oncologic Efficacy

Table 4 lists the histopathologic results of specimens obtained via laparoscopic radical nephroureterectomy from large single-institution published series, representing a total of 198 international patients. Most lesions in these patients (52-94%) were high grade. Most patients with low-stage, low-grade transitional cell carcinoma of the upper urinary tract have favorable long-term outcomes after nephroureterectomy, whereas those with high-stage, high-grade disease have significantly poorer survival rates (2,4). One- and two-year follow-up data thus far show cancer-specific survival rates of 63% to 97% in 154 patients after laparoscopic radical nephroureterectomy compared with 53% to 87% in 156 patients after open nephroureterectomy followed up for 1.5 to 4 years (Table 5). Positive margin rates have not been consistently reported by all institutions but appear to be equivalent for the few studies reporting results of both approaches. Bladder recurrence rates in the open (24-64%) and laparo-scopic (9-54%) groups were within expected ranges. Rates of local and distant recurrence were likewise comparable between open (0-24% and 0-23%, respectively) and laparoscopic (0-15% and 0-23%, respectively) groups. All patients who underwent open nephroureterectomy had longer follow-up. This lead-time bias accounts for the perceived higher rates of bladder, local, and distant recurrence in these open cohorts (Table 5). In one of the largest published series of open nephroureterectomy, Hall et al. (2) reported five-year disease-specific survival rates of 100%, 92%, 73%, and 41% in 252 patients with stage Ta/Tis, T1, T2, and T3 disease, respectively (Fig. 3). While most recurrences for this disease tend to occur within the first two years, follow-up for laparoscopic radical nephroureterectomy is limited, not only temporally but also by small patient numbers, and the availability of long-term data will be critically important in unequivocally establishing oncologic efficacy. The data thus far, however, supports its continued selective application.

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