Anatomical distribution and predictors of lymph node metastasis in robot-assisted radical nephroureterectomy for upper tract urothelial carcinoma: a multicenter study by the Junior ERUS/YAU Robotic Surgery Working Group
Por:
Di Maida, F, Lambertini, L, Bravi, CA, De Groote, R, Piramide, F, Turri, F, Wenzel, M, Sharma, G, Würnschimmel, C, Lambert, E, Dell'Oglio, P, Moschovas, MC, Campi, R, Grosso, AA, Liakos, N, Mayr, R, Darlington, D, Eraky, A, Paciotti, M, Sorce, G, Tappero, S, Mottaran, A, Larcher, A, Montorsi, F, Briganti, A, Crisan, N, Mottrie, A, Minervini, A, Breda, A, Andras, I
Publicada:
11 abr 2026
Ahead of Print:
1 abr 2026
Resumen:
Introduction The role of lymph node dissection (LND) during robot-assisted nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains debated, particularly in clinically node-negative (cN0) patients. This study aimed to evaluate the anatomical distribution of nodal metastases, identify predictors of lymph node positivity, and assess perioperative and oncological outcomes associated with LND. Methods A retrospective multicenter study was conducted including 511 patients treated with RNU for UTUC at multiple high-volume international referral centers between 2019 and 2023. Among them, 218 (42.7%) underwent LND, including 159 with cN0 disease. Multivariable logistic regression identified predictors of nodal positivity. To assess the impact of LND on oncologic outcomes, multivariable Cox proportional hazards models were fitted for metastasis-free survival (MFS), adjusting for clinically relevant covariates. Results Patients undergoing LND were younger and had larger tumors. LND was associated with longer operative time and a higher rate of major complications (6.9% vs 1.7%). Adverse pathological features (pT >= 2, necrosis, lymphovascular invasion) were more common in the LND group. Among cN0 patients, 17.6% harbored occult nodal metastases. Hilar and iliac-obturator fields yielded the highest positivity rates, while retrocaval and presacral dissections showed none. Larger clinical tumor size was the only independent preoperative predictor of pN + (OR 1.008 per mm; 95% CI 1.002-1.017; p = 0.001). Kaplan-Meier analysis showed improved MFS in cN0 patients treated with LND (p = 0.045), whereas RFS and OS did not differ between groups. In the multivariable Cox model, LND showed a non-significant trend toward reduced metastatic progression, while cT3 stage was strongly associated with worse MFS. Conclusions LND during RNU enhances staging accuracy and identifies a clinically relevant proportion of occult metastases in cN0 UTUC patients. Tumor size is the key preoperative predictor of nodal positivity. Although LND improves MFS in unadjusted analyses, its independent therapeutic effect remains uncertain. These findings support a selective, risk-adapted approach to LND that integrates tumor size and anatomical drainage patterns.
Filiaciones:
Di Maida, F:
Univ Florence, Careggi Hosp, Dept Expt & Clin Med, Unit Urol & Androl, Largo Brambilla 3, I-50134 Florence, Italy
Lambertini, L:
Univ Florence, Careggi Hosp, Dept Expt & Clin Med, Unit Urol & Androl, Largo Brambilla 3, I-50134 Florence, Italy
Bravi, CA:
Royal Marsden NHS Fdn Trust, Dept Urol, London, England
Northampton Gen Hosp, Dept Urol, Northampton, England
Onze Lieve Vrouwziekenhuis Hosp, Dept Urol, Aalst, Belgium
ORSI Acad, Ghent, Belgium
De Groote, R:
Onze Lieve Vrouwziekenhuis Hosp, Dept Urol, Aalst, Belgium
ORSI Acad, Ghent, Belgium
Piramide, F:
Univ Turin, San Luigi Gonzaga Hosp, Dept Oncol, Div Urol, Orbassano, Italy
Turri, F:
Univ Cattolica Sacro Cuore, Fdn Policlin Univ A Gemelli IRCCS, Dept Urol, Rome, Italy
Wenzel, M:
Goethe Univ Hosp Frankfurt, Dept Urol, Frankfurt, Germany
Sharma, G:
Medanta Medicity, Dept Urol Oncol, Gurgaon, India
Würnschimmel, C:
Univ Teaching & Res Hosp Lucerne, Dept Urol, Luzern, Switzerland
Lambert, E:
Onze Lieve Vrouwziekenhuis Hosp, Dept Urol, Aalst, Belgium
Ghent Univ Hosp, Dept Urol, Ghent, Belgium
Dell'Oglio, P:
ASST Grande Osped Metropolitano Niguarda, Urol Dept, Milan, Italy
Moschovas, MC:
AdventHlth Global Robot Inst, Celebration, FL, USA
Campi, R:
Univ Florence, Careggi Univ Hosp, Dept Expt & Clin Med, Unit Urol & Renal Transplantat, Florence, Italy
Grosso, AA:
Univ Florence, Careggi Hosp, Dept Expt & Clin Med, Unit Urol & Androl, Largo Brambilla 3, I-50134 Florence, Italy
Liakos, N:
Univ Freiburg, Fac Med, Dept Urol, Med Ctr, Freiburg, Germany
Mayr, R:
Univ Regensburg, Caritas St Josef Med Ctr, Dept Urol, Regensburg, Germany
Darlington, D:
Royal Surrey NHS Fdn Trust, Dept Urol, Guildford, England
Eraky, A:
Icahn Sch Med Mt Sinai, Dept Urol, New York, NY, USA
Paciotti, M:
IRCCS Humanitas Res Hosp Rozzano, Dept Urol, Milan, Italy
Sorce, G:
Univ Messina, Dept Clin & Expt Med, Urol Sect, Messina, Italy
Tappero, S:
ASST Grande Osped Metropolitano Niguarda, Urol Dept, Milan, Italy
Mottaran, A:
IRCCS Azienda Osped Univ Bologna, Bologna, Italy
Larcher, A:
IRCCS San Raffaele Hosp, Dept Urol, Milan, Italy
Montorsi, F:
IRCCS San Raffaele Hosp, Dept Urol, Milan, Italy
Briganti, A:
IRCCS San Raffaele Hosp, Dept Urol, Milan, Italy
Crisan, N:
Iuliu Hatieganu Univ Med & Pharm, Dept Urol, Cluj Napoca, Romania
Mottrie, A:
Onze Lieve Vrouwziekenhuis Hosp, Dept Urol, Aalst, Belgium
ORSI Acad, Ghent, Belgium
Minervini, A:
Univ Florence, Careggi Hosp, Dept Expt & Clin Med, Unit Urol & Androl, Largo Brambilla 3, I-50134 Florence, Italy
Breda, A:
Fundacio Puigvert, Dept Urol, Barcelona, Spain
Andras, I:
Iuliu Hatieganu Univ Med & Pharm, Dept Urol, Cluj Napoca, Romania
Green Submitted, gold
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