Laparoscopic or open nephroureterectomy: which is the more efficient way to go?

Upper urinary tract transitional cell carcinoma (UTCC) is a rare disease but is associated with high recurrence rates and significant risk of progression. Open radical nephroureterectomy (ONU) has been the standard treatment for several decades. Because the performance of the open procedure requires either two incisions or an extended flank incision, the laparoscopic nephroureterectomy (LNU) is an appealing option. LNU is associated with less intraoperative blood loss, decreased postoperative pain, and decreased hospital stay [1,2]. Although there is always a standing question about the oncologic efficacy of newer laparoscopic approaches, the low incidence of urothelial carcinoma of the upper urinary tract represents a problem for the evaluation of the LNU outcome regardless of the follow-up period. Several single-institution studies with limited experience have been published, and the majority of these investigators have concluded that LNU should be performed in patients with favorable tumor characteristics, while ONU should take place in the advanced tumor cases [1–6]. A large multi-institutional noncomparative study including 1363 patients who underwent ONU (n = 1050) or LNU (n = 313) was reported recently [7]. Complete resection of the distal ureter was performed in all cases, while lymphadenectomy took place in 46.8% and 31.6% of the ONUs and LNUs, respectively. The extent of the lymphadenectomy varied widely among the institutions. A limited portion of the studied population was managed by neoadjuvant (3%) and/or adjuvant chemotherapy (13%), respectively. The median follow-up period of the study was 37.2 mo (range: 1.2–250 mo). High-grade tumors, lymphovascular invasion, sessile tumor architecture,