Comparison of Oncologic Outcomes for Open and Laparoscopic Nephroureterectomy: A Multi-Institutional Analysis of 1249 Cases

Background

Data regarding the oncologic efficacy of laparoscopic nephroureterectomy (LNU) compared to open nephroureterectomy (ONU) are scarce.

Objective

We compared recurrence and cause-specific mortality rates of ONU and LNU.

Design, setting, and participants

Thirteen centers from three continents contributed data on 1249 patients with nonmetastatic upper tract urothelial carcinoma (UTUC).

Measurements

Univariable and multivariable survival models tested the effect of procedure type (ONU [n = 979] vs LNU [n = 270]) on cancer recurrence and cancer-specific mortality. Covariables consisted of institution, age, Eastern Cooperative Oncology Group (ECOG) performance status score, pT stage, pN stage, tumor grade, lymphovascular invasion, tumor location, concomitant carcinoma in situ, ureteral cuff management, previous urothelial bladder cancer, and previous endoscopic treatment.

Results and limitations

Median follow-up for censored cases was 49 mo (mean: 62). Relative to ONU, LNU patients had more favorable pathologic stages (pT0/Ta/Tis: 38.1% vs 20.8%, p < 0.001) and less lymphovascular invasion (14.8% vs 21.3%, p = 0.02) and less frequently had tumors located in the ureter (64.5 vs 71.1%, p = 0.04). In univariable recurrence and cancer-specific mortality models, ONU was associated with higher cancer recurrence and mortality rates compared to LNU (hazard ratio [HR]: 2.1 [p < 0.001] and 2.0 [p = 0.008], respectively). After adjustment for all covariates, ONU and LNU had no residual effect on cancer recurrence and mortality (p = 0.1 for both).

Conclusions

Short-term oncologic data on LNU are comparable to ONU. Since LNU was selectively performed in favorable-risk patients, we cannot state with certainty that ONU and LNU have the same oncologic efficacy in poor-risk patients. Long-term follow-up data and morbidity data are necessary before LNU can be considered as the standard of care in patients with muscle-invasive or high-grade UTUC.     

Twiddler's syndrome: Between mechanical recoil and behavioral troubles

A 72-year-old male with severe dilated cardiomyopathy, benefited of implantable cardiac defibrillator implementation. Device control shows high impedance. On X-ray, electrodes were completely twisted in the generator pocket, they were replaced and the generator was fixed to pectoralis-major fascia. Nurses report patient abnormal movements, scratching implantation area. This was identified as probably the trigger of the complication.     

Isolated Right Ventricular Air Embolism

Vascular air embolism (VAE) is an uncommon but potentially life-threatening event often associated with various procedures and diagnostic tests. Understanding this challenging incident will enable physicians to evaluate, diagnose and manage this incident successfully. We present a case of a 73-year-old male who developed air in the right ventricle after intravenous contrast-enhanced computed tomography (CT) imaging. We aim at highlighting this challenging clinical scenario and emphasizing ways to assess the risks and implement means to prevent and treat accordingly.