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Introduction <p>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.</p> Methods <p>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.</p> Results <p>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.&#xa0;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; <i>p</i> = 0.001). Kaplan–Meier analysis showed improved MFS in cN0 patients treated with LND (<i>p</i> = 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.</p> Conclusions <p>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.</p>

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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

  • 期刊论文

  • 发表日期：

    2026年4月11日

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  • Fabrizio Di Maida,
  • Luca Lambertini,
  • Carlo Andrea Bravi,
  • Ruben De Groote,
  • Federico Piramide,
  • Filippo Turri,
  • Mike Wenzel,
  • Gopal Sharma,
  • Christoph Würnschimmel,
  • Edward Lambert,
  • Paolo Dell’Oglio,
  • Marcio Covas Moschovas,
  • Riccardo Campi,
  • Antonio Andrea Grosso,
  • Nikolaos Liakos,
  • Roman Mayr,
  • Danny Darlington,
  • Ahmed Eraky,
  • Marco Paciotti,
  • Gabriele Sorce,
  • Stefano Tappero,
  • Angelo Mottaran,
  • Alessandro Larcher,
  • Francesco Montorsi,
  • Alberto Briganti,
  • Nicolae Crisan,
  • Alexandre Mottrie,
  • Andrea Minervini,
  • Alberto Breda,
  • Iulia Andras

摘要

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.