Robotic Surgery of the Urothelial Carcinoma of the Upper Urinary Tract Single Surgeon Initial Experience, 66 consecutive cases

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Wagenlehner This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4511142/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Nov, 2024 Read the published version in BMC Urology → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: Robotic surgery is increasingly utilized in the treatment of urothelial carcinoma of the upper urinary tract (UTUC). This study investigates the advantages and burden of robot-assisted surgical treatment of the urothelial carcinoma of the upper urinary tract in a referral urological department, along with their functional and oncological results. Methods : The study included 66 prospectively enrolled patients who were surgically treated by a single, robotically specialized surgeon between July 2019 and December 2023. Patients were divided into three groups. Group 1: 50 patients underwent robot-assisted radical Nephroureterectomy (RANU) with bladder cuff excision, Group 2: 11 patients underwent RANU simultaneously with robot-assisted radical cystectomy (RARC), and Group 3: 5 patients underwent robot-assisted segmental ureterectomy (RASU). Clinical and oncological parameters were compared. Perioperative morbidity according to Clavien-Dindo was the primary endpoint of our study. The secondary endpoint was oncologic outcomes. Results: 37.8% of patients had locally advanced carcinomas. The average console time of RANU with bladder cuff excision was 69 minutes. The rate of positive surgical margins was n=1/66 (2%). Lymphadenectomy (LAD) was performed on 30% of patients, with a mean of 13.7 lymph nodes removed. Of those who received LAD, 33% had lymph node metastasis. n=6/66 (9%) patients received blood transfusion. The overall complication rate was 24%. The readmission rate was 7.5%. With a median follow-up of 26 months, the 2-year recurrence-free survival rate was 84.4%, and the 2-year overall survival rate was 94%. Conclusion: Robotic surgery is a feasible option for treating UTUC that can be adapted to meet the surgical needs of each patient. Prospective studies are warranted to confirm its benefits. upper urinary tract carcinoma (UTUC) RANU RARC segmental ureterectomy 1. Introduction Upper urinary tract carcinoma (UTUC) accounts for approximately 7% of all urothelial cancers (1). Previous series mostly focused on either comparison between open versus laparoscopic radical nephroureterectomy (LNU) (2, 3) (4) or laparoscopic versus robotic nephroureterectomy (RANU) (5) (6-8). Since LNU is a challenging procedure concerning bladder cuff excision, many surgeons tended to combine the laparoscopic approach with an open ureterectomy (9). However, Peyronnet et al. suggested that oncological outcomes of LNU may be less favorable than those of open radical nephroureterectomy (RNU) when the bladder cuff is excised laparoscopically, particularly in patients with locally advanced high-risk tumors (4). Also, the impact of lymphadenectomy (LAD) on clinical outcomes during radical nephroureterectomy (RNU) was also investigated by various authors (10-12). For example, Yoo et al. found that LAD may impact the 5-year recurrence-free survival (13). In consequence, a lymphadenectomy should be ideally performed during RNU. Second, in patients with low-risk / low-grade and noninvasive UTUC a kidney-sparing approach represents an important therapeutic option (14). In this context, the robot-assisted approach might mitigate potential disadvantages of the laparoscopic approach and provide a solution for adequate oncological outcomes, sufficient lymphadenectomy and kidney sparing in select patients. Data is still very limited, but RANU is increasingly utilized in the surgery of UTUC (15, 16). For example, Yajima et al. reported a case of simultaneous RANU with robot-assisted radical cystectomy (RARC)(17). Thus, we investigated the complications and oncological outcomes of robot-assisted radical nephroureterectomy (RANU) and robot-assisted segmental ureterectomy (RASU) patients in a referral urological department performed by a single robotic expert surgeon. 2. Methods We performed 66 consecutive procedures transperitoneally with the Da Vinci X® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Surgeries were performed by a single robotic-expert surgeon with a caseload of over 2000 combined robotic procedures. Hilar, paraaortic, retrocaval and interaortocaval lymphadenectomy was performed in kidney pelvis tumor cases, in which lymph nodes were deemed suspicious on preoperative CT scans or when tumours met high-risk criteria according to EAU guidelines for UTUC (1). In case of high-risk ureteral urothelial cancers, the iliac lymph nodes were removed. Group 1 was defined as RANU patients. They also received a bladder cuff excision, and no drain was inserted. Group 2 was defined as RANU patients with simultaneous RARC. In those, the resected kidney was removed in an en-bloc approach with the bladder and a drain was inserted in this group. Group 3 was defined as RASU patients, i.e. distal ureterectomy, who received a catheter insertion and a bladder closure. These patients did not receive any drains. In group 1 and 3, a cystography was performed on third day after surgery. When cystography was uneventful, patients received mitomycin and the catheter was removed. Overall, 66 patients underwent RANU and RASU between July 2019 and December 2023. We compared demographic and perioperative parameters between groups. Postoperative complications were graded using the Clavien-Dindo classification(18). Follow-ups were performed regularly according to EAU guidelines(1). Data was collected prospectively in an institutional database and analyzed with SPSS® v27. Categorical variables were presented as frequencies, while continuous variables were presented as mean values. Kolmogorov-Smirnov test verified normal distribution. Independent T-test and Mann-Whitney U test were used for matched-pair analysis of parametric and non-parametric variables, respectively. Pearson's chi-square test was used to compare relative frequencies. For parametric numeric variables, a one-way ANOVA test was performed, followed by a post hoc comparison (Bonferroni) test if needed. The independent samples Kruskal-Wallis test was used for nonparametric variables. The study was conducted under the ethical standards of the Declaration of Helsinki and approved by the ethics committees of the medical association Westfalen-Lippe and Wilhelm’s University of Muenster (2023-500-f-S). 3. Results Baseline Parameters : Patients were grouped according to surgical procedure they received for UTUC treatment (Table 1). Group 1 had 50 patients who underwent RANU, Group 2 had 11 patients who had RANU simultaneously with RARC, and Group 3 had 5 patients who underwent RASU. Overall, patients’ mean age was 71 years with similar distribution among groups (p=0.7). Their average BMI was 31 with no variation among groups (p=0.9). 45% of patients were classified as ASA 3 with no statistical differences observed among groups (p=0.38). Group 2 patients had confirmed preoperative histological tumors, while only 20% in group 1 did (p=0.014). Hence in group 1, surgery was also based on clinical and radiographic diagnosis, even with negative or equivocal endourological biopsy results. Group 2 had the most advanced tumours, with 80% of them being at least clinical T2 tumors (p=0.014). Group 1 had the highest intake of anti-coagulation medication, with 15 (33%) patients taking aspirin (p=0.003). Overall, n=8/66 (12%) patients received neoadjuvant platin-based chemotherapy. All other study parameters were similar between the groups. Further details are given in Table 1. Intra- and perioperative data: Overall, the average console time was 63 minutes (Table 2). Group 2 patients, who received RANU simultaneous with RARC, had the shortest time at 42 minutes for the RANU procedure vs. the longest time in RASU patients at 73 minutes (p=0.065 ). Overall, 38% of patients had locally advanced carcinomas and statistical analysis showed no significant difference for tumor stage between groups (p=0.18). 62% of patients had high-risk carcinomas (p=0.3), and only one patient in the study had a positive surgical margin. Among those, who received a LAD (n=20), the mean number of lymph nodes removed was 13.7, with a maximum mean number of 22 in group 2, (p=0.035). In the same group of those, who received a LAD, 6 (33%) were positive for LN metastases. The mean hospital stay for all patients was 8.1 days, with the longest stay in group 2 at 10 days, which was statistically significantly longer compared to other study groups (p=0.4). Overall, 6 out of 66 patients (9%) received a perioperative blood transfusion, with no significant difference between the study groups (p=0.6). More details in table 2. Complications: Group 2 Patients (36%) had more complications than group 1 (24%) und group 3 (0%) (p=0.04). Overall 5/66 patients (8%) were readmitted within 90 days after discharge. The statistical analysis showed no difference between groups (p=0.8). The most common major complication we observed, was 4 incisional hernias on the mini-laparotomy site, that was used to extract the specimen. One female patient developed an embolus of the arteria iliaca externa and had to undergo an emergency embolectomy. One 90-year-old male patient experienced bleeding on the first operative day with a hemoglobin decrease of more than 6 g/dl after an uneventful intraoperative course. One male patient had a diagnostic laparascopy due to suspicion of mechanical bowel obstruction, which was not confirmed, and resolved thereafter after further medical bowel stimulation. The final complication was wound infection which necessitated wound revision and a superficial Vacuum-assisted closure system. The surgery-related mortality rate at 3 months in our cohort was 3%; n=2/66. Specifically, two geriatric patients over 80 years old received palliative surgery due to persistent macrohematuria, refractory to endosurgical treatments. Of those, the first, female patient died due to cardiac decompensation. The second, male patient had a hostile abdomen due to previous surgeries, underwent bowel adhesiolysis and bowel resection, before the robot-assisted nephroureterectomy and later died due to multiorgan insufficiency. More details in table 3. Oncological Results: In group 1, in 10% of patients, a tumor could not be detected in the final pathology. Of those, 2 patients had neoadjuvant chemotherapy, 2 patients had highly suspicious tumor findings in the multiphase contrast enhanced CT-Scan and one young, 42 year old, male patient had endoscopically proven ureteral cancer. Postoperatively, n=26/50 (52%) patients received mitomycin. 5 patients received adjuvant platin-based chemotherapy while 3 patients received checkpoint inhibitors. The median follow-up in our series is 26 months (interquartile range from 9 to 43 months). One patient with locally advanced UTUC had local recurrence at the kidney site, while 6 (9%) patients had bladder recurrence and 4 (6%) patients had distant metastasis. We recorded 3/66 (4,5%) cancer-related deaths and 1 (1,5%) death due to other reasons. The recurrence-free survival in our study was 84,4% at 24 months. While the cancer-specific survival was 95% at 24 months, the overall survival was virtually identical at 94% at 24 months. Details are given in table 3. 4. Discussion With the increased adoption of robotic surgery in the treatment of urothelial malignancies including UTUC, the vast majority of related literature focused on the comparison between the different surgical approaches and their results in context of UTUC(2-4). Some surgeons combined different approaches, such as laparascopy and open surgery with robot-assisted surgery to gain the best possible results(6) (9). Some investigated the potential benefit of LAD during nephroureterectomy(10). However, to this date, previous series are very sparse and mostly limited due to small sample sizes and/or still maturing surgical expertise. For example, the multicenter study by Campi et al. relied on a total combined cohort of 81, with a highly variable robotic caseload(19). Moreover, similar to RARC patients UTUC patients represent a highly variable patient cohort, young and fit patients vs. senior patients with high comorbidity burden and previous surgical interventions(20). Thus, we relied on a real world cohort without strict selection criteria with an adequate sample size and a single robotic-surgeon expert with a combined caseload of over 2000 combined robotic procedures (i.e RARP, RARCs and complete or partial nephrectomies). This is reflected by three different robot-assisted surgical methods, RANU, combined RANU in en-bloc fashion and RASU. Moreover, we relied on comprehensive results, i.e. intra- and perioperative data including complications and oncological follow-up. Our study had important findings. First, mean age of 71, a mean BMI of 31 that denotes obese patients and a majority of ASA3 status proportion overall indicate a challenging, but real-life patient cohort. Similarly, tumor characteristics are reflected in the careful choice of surgery approach. Second, it is important to note that in our real-world cohort, 10% of patients could benefit from a kidney-sparing (i.e. RASU) approach if tumor localization and size were carefully considered. In 11 out of 66 cases (16%) with an aggressive, muscle-invasive bladder carcinoma accompanied by UTUC, a combined RANU and RARC procedure was found to be feasible. Third, our intra- and perioperative characteristics indicate rather short surgical times and low Clavien-Dindo Complication (CDC) rates, demonstrating that the robot-assisted UTUC surgery is particularly suited with respect to perioperative morbidity for a comorbidity-burdened patient cohort. The surgical efficiency and outcomes might be attributed to two aspects. First, the surgical experience of almost 2000 robotic procedures, which is considered a super-expert (21, 22) and second, the single docking of the robot, i.e. no repositioning of the patient and no re-docking during the procedure. This notion and corresponding causality is supported by Yajima et al., who reported the first case of combined RANU and RARC in Japan. They reported RANU console time to be 66 (RANU) and 207 (RARC) minutes which is in accordance with our findings (42 minutes for RANU in group 2)(17). Moreover, Kamei et al. compared the en-bloc cystectomy with radical nephroureterectomy between 17 open-surgical and 10 robot-assisted patients and found the minimally invasive approach to be non-inferior (23). These findings clearly demonstrate the need to include surgical expertise in analyzing results of such robot-assisted surgeries as in our study at hand, going hand-in-hand with the en-bloc approach. Fourth, in the study at hand technical feasibility included LAD, which prognostic impact remains of great debate. For example, Inokuchi et al. reported simultaneous LAD, with consistent mean LAD yield compared to our study(10). Specifically, Dominguez-Escrig et al. reported that template-based and complete lymph node dissection improves cancer-specific survival (CSS) in patients with high-stage UTUC and reduces the risk of local recurrence (11). Thus, a LAD remains an important cornerstone in UTUC surgery. The number of removed lymph nodes ranged between 5,5 and 21 (5, 13). Yoo et al. found that 12.1% who underwent lymph node dissection, had pathological lymph node metastasis in their final pathology (13). Similarly, De Groote et. al performed LAD in 41% of patients and found lymph node involvement in 29% (15). In our study, the mean number of removed lymph nodes was 13.7 similar to other publications(5) (13). Furthermore, we performed LAD only in high-risk patients and or when suspicion was given in a CT scan preoperatively. Similarly, we found metastasis in 33% of patients, who underwent LAD. Taken together, our findings are consistent with previous series and demonstrate that LAD during RANU with or without RARC is highly feasible. Fifth, despite high comorbidity burden our cohort experienced an overall major complication rate (i.e. CDC III a or higher) of 17%. These results are lower than reported by other surgeons (5, 6, 15). However, we did not yet apply the most recent Comprehensive Complication Index (CCI®) introduced by Slankamenac, adopted for open radical cystectomy by Vetterlein et. al and first adopted by Mendrek et al. for RARC(24-26). Such new metrics will enable better comparison between centres, patient counselling and enable greater granularity for such complex surgery as in our current study. Interestingly, the readmission rate was relatively low at 7.5%, compared to 8.2% reported by Liedberg et al(27). Sixth, in our study, 9% of patients had bladder recurrence and 6% had distant metastasis. These findings are highly consistent with open UTUC series. Hemal et al. found no local recurrence in their series of 48 patients (9). In our study, we observed one local recurrence at the kidney site. However, in the study conducted by Hemal et al., almost 10% of patients in both arms experienced bladder recurrence and distant metastases. The authors reported the 5-year recurrence-free survival, cancer-free and overall survival in their laparoscopic LNU arm to be 90,4% , 95,2% and 85,7% respectively (9). Campi et al. reported 20% ipsilateral upper tract recurrence after RASU, and 7.5% distant metastases after RANU (19). We reported our data with mean follow-up of 28 months. While the Recurrence-free survival at a median follow up of 26 months in our study was 84,4%, our patients had similar cancer-specific 95,4% and superior overall survival at 94%. De Groote et al. found 4-year Overall survival (OS) of 66% and recurrence-free survival (RFS) and 53% at a median follow-up of 15 months (15). Finally, our study mortality rate at 24 months is 3% (2/66) patients. Our rate is higher than what has been reported by others (20). However, it is of note that our data relies on a real-life cohort and that the large confidence interval is not suited for comparability. Moreover, this could be attributed to the extensive comorbidities in some of our patients. Another reason could be that a significant portion of our patients underwent surgery in almost palliative symptomatic settings due to persistent uncontrolled macrohematuria. Seisen et al. proposed, in their systematic review dealing with the safety of kidney-sparing surgery (KSS) for UTUC and comparing it to RANU, similar survival after Kidney sparing surgery (KSS) versus RANU only for low-grade and noninvasive UTUC when using endourological interventions (14). In our study, only 5 out of 55 patients (10%) were suitable candidates for RASU. Among these patients, two had high-stage tumours, T2 and T3. This finding is consistent with Seisen and colleagues’ suggestion that selected patients with high-grade and invasive upper tract urothelial carcinoma (UTUC) could benefit safely from this type of surgery when feasible. Out study has limitations. Our analyses were performed retrospectively. To ensure the study reflected real-world scenarios, all consecutive patients from aforementioned three treatment groups were included, representing different UTUC procedures. Nonetheless despite that sample size, in comparison, 66 cases in 4 years in one center is indiciates a higher number for a single center compared to 78 cases over 10 years in 3 high volume robotic surgery centers (15). In consequence future series are necessary to confirm our findings. Specifically, our findings still serve as a proof of feasibility and proof of favorable patient outcomes. Thus, we anticipate further widespread adoption of the techniques reported in our study. Additionally, it’s worth noting that the study was conducted in a high-volume robotic tertiary center. Therefore the findings may not apply to other centers with different surgical focus or different caseloads . Conclusion Robotic surgery is a viable treatment option for urothelial carcinoma of the upper urinary tract if performed by an experienced surgeon. It can be used flexibly depending on the surgical indication and the specific patient cohort. Prospective studies are warranted to confirm its proposed benefits. Abbreviations CDC: Clavien-Dindo Complication UTUC: upper urinary tract carcinoma RANU: robot-assisted radical nephroureterectomy RARC: robot-assisted radical Cystectomy RASU: robot-assisted segmental ureterectomy UC: urothelial carcinoma LNU: Laparoscopic radical nephroureterectomy LAD: Lymphadenectomy LN: Lymph nodes AC anticoagulation ASA American association of anesthesiology score BMI body mass index Hgb hemoglobin PSM positive surgical margins CCS cancer specific survival RFS recurrence free survival OS overall survival BR bladder recurrence Declarations Ethics approval and consent to participate The study was conducted under the ethical standards of the Declaration of Helsinki and approved by the ethics committees of the medical association Westfalen-Lippe and Wilhelm’s University of Muenster (2023-500-f-S) date 21.11.2023.The need for informed consent was waived by the ethic committees of the Medical Association Westfalen-Lippe and Wilhelm’s University of Münster (2023-500-f-S) date 21.11.2023 Consent for publication Not applicabl. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to national regulations on perosnal data protection but are available from the corresponding author on reasonable request. Competing Interests All authors declare that they have no conflicts of interest to disclose. Funding The authors received no funding for this study Authors' contributions Conceptualization, M.F. and S. LB.; Methodology, M.F.; Software, M.F. ; Validation, M.F.; Formal analysis, M.F. ; Investigation, M.F.; Data curation, M.F.; Writing—original draft M.F., S. LB. and F.W.; Writing—review & editing, M.F. S. LB and F.M.W.; Visualization, M.F.; Supervision, M.F., S. LB. and F.M.W.; Project administration, M.F. and F.M.W.; Funding acquisition, not applicable. Acknowledgements none References Rouprêt M, Seisen T, Birtle AJ, Capoun O, Compérat EM, Dominguez-Escrig JL, et al. 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The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1-7. Vetterlein MW, Klemm J, Gild P, Bradtke M, Soave A, Dahlem R, et al. Improving Estimates of Perioperative Morbidity After Radical Cystectomy Using the European Association of Urology Quality Criteria for Standardized Reporting and Introducing the Comprehensive Complication Index. Eur Urol. 2020;77(1):55-65. Mendrek M, Witt JH, Sarychev S, Liakos N, Addali M, Wagner C, et al. Reporting and grading of complications for intracorporeal robot-assisted radical cystectomy: an in-depth short-term morbidity assessment using the novel Comprehensive Complication Index(®). World J Urol. 2022;40(7):1679-88. Liedberg F, Abrahamsson J, Bobjer J, Gudjonsson S, Löfgren A, Nyberg M, et al. Robot-assisted nephroureterectomy for upper tract urothelial carcinoma-feasibility and complications: a single center experience. Scand J Urol. 2022;56(4):301-7. Tables Table 1: Analysis of demographic and baseline characteristics: UTUC Total (N=66) Group 1 RANU N=50 (77%) Group 2 Combined RANU and RARC N=11 (16%) Group 3 Robot-assisted segmental Ureterectomy N= 5 (7,6%) p-Value Age (years), mean 71 72 69 70 0.7 BMI (kg/m 2 ), mean 31 31 32 31 0.9 ASA-score 1 2 3 20 (30) 16 (24) 30 (45,5) 14 (28) 11 (22) 25 (50) 5 (45) 3 (27) 3 (27) 1 (20) 2 (40) 2 (40) 0.4 Preoperative Hgb (g/dl), mean 12.2 12.2 11.8 12.8 0.7 Tumor location Intramural ureter Other parts of Ureter Kidney pelvis Multifocal 12 (18) 18 (27) 34 (51) 2 (3) 3 (6) 12 (24) 33 (66) 2 (4) 9 (81) 1 (9) 1 (9) 0 5 (100) 0 0 0 Preoperative Histology No Histology Tis Ta T1 T2 T3 T4 44 (66) 1 (1,5) 11 (16) 1 (1,5) 8 (12) 0 1 (1,5) 40 (80) 0 9 (18) 1 (2) 0 0 0 0 1 (9) 1 (9) 0 8 (72) 0 1 (9) 4 (80) 0 1 (20) 0 0 0 0 0.014 Neoadjuvant Chemotherapy 2 cycles cisplatin-Gemcitabine 3 cycles cisplatin-Gemcitabine 4 cycles cisplatin-Gemcitabine 6 cycles cisplatin-Gemcitabine 2 (3) 1 (1,5) 2 (3) 3 (4,5) 0 1 (2) 0 1 (2) 1 (9) 1 (9) 2 (18) 2 (18) 0 0 0 0 0.001 Anti-coagulation Aspirin NOAC 0 19 (13,6) 6 (9) 0 15 (30) 3 (6) 0 3 (27) 0 0 1 (20) 3 (60) 0.003 Time from first diagnosis to procedure (months), mean 1.3 1.27 1.1 2 0.5 Categorical data are presented as numbers %, UTUC: Upper Urinary Tract Urothelial Cell Carcinoma, RANU: robot-assisted nephroureterctomy, RARC: robot-assisted radical cystectomy. BMI: body mass index, ASA: American Association of Anesthesiology Morbidity Score, Hgb: hemoglobin, NOAC: new oral anticoagulants, Table 2: Intra- and postoperative data and pathological findings between groups: UTUC Total (N=66) Group 1 RANU N=50 (77%) Group 2 Combined RANU and RARC N=11 (16%) Group 3 Robot-assisted segmental Ureterectomy N= 5 (7,6%) p-Value Console time (minute), mean (SD) 63 (34) 69 (37) 42 (15) 73 (12) 0.065 Pathological tumor stage, n (%)* pT0 pTa pT1 pT2 pT3 pT4 5 (7,5) 11 (16) 12 (18) 13 (19,6) 21 (32) 4 (6) 5 (10) 9 (18) 11 (22) 10 (20) 15 (30) 0 0 0 0 2 (18) 5 (45) 4 (36) 0 2 (40) 1 (20) 1 (20) 1 (20) 0 0.18 Urothelial carcinoma grade*, n (%) 0 1 2 3 5 (7,5) 14 (21) 5 (7,5) 41 (60) 5 (10) 11 (22) 5 (10) 29 (58) 0 0 0 11 (100) 0 3 (60) 0 2 (40) 0.3 Postoperative Chemotherapy (yes. vs. none), n (%) 2 cycles cisplatin-Gemcitabine, n (%) 3 cycles cisplatin-Gemcitabine, n (%) 4 cycles cisplatin-Gemcitabine, n (%) 6 cycles cisplatin-Gemcitabine, n (%) Initiation of CI therapy, n (%) 2 (3) 1 (1,5) 1 (1,5) 1 (1,5) 3 (4,5) 0 1 (2) 0 0 1 (2) 2 (18) 0 1 (9) 1 (9) 1 (9) 0 0 0 0 1 (20) 0.3 Positive surgical margins (total), (%) 1 (1,5) 0 1 (9) 0 0.8 Number of patients, who received a lymphadenectomy, n (%) 20 (30) 10 (20) 9 (81) 1 (20) 0.001 Number of lymph nodes removed in patients, who received a lymphadenectomy, mean (SD) 13.7 (13.7) 7 (10) 22 (13) 2 (0) 0.035 Number of patients, who had a lymphadenectomy and had metastases among the total number of surgically treated patients 6/20 (33%) 1/10 (10%) 5/9 (55%) 0/1 0.002 Length of hospitalization (days), mean (SD) 8.1 (6.5) 7.9 (7) 10 (5.5) 5.8 (1) 0.4 Transfusion rate, n (%) 6 (9%) 4 (8) 2 (18) 0 0.6 * patients with multiple tumours: the most significant cancer was listed, Categorical data are presented as numbers %, UTUC: Upper Urinary Tract Urothelial Cell Carcinoma, RANU: robot-assisted nephroureterctomy, RARC: robot-assisted radical cystectomy. SD: standard deviation, CI: Check point inhibitor, * Grade according to WHO classification 1999 (Busch et al.)[Busch, 2002 #251] Table 3: Complications, readmissions and oncological long term results among study groups, Follow up time-lapse 3-48 Months UTUC Total (n=66) Group 1 RANU N=50 (77%) Group 2 Combined RANU and RARC N=11 (16%) Group 3 Robot-assisted segmental Ureterectomy N= 5 (7,6%) p-value total 16 (24) 12 (24) 4 (36) 0 0.04 Minor CDC I 4 (6) 4 (8) 0 0 CDC II 1 (1,5) 0 1 (9) 0 Major CDC IIIa 1 (1,5) 1 (2) 0 0 CDC III b 7 (10,6) 4 (8) 3 (27) 0 CDC VI 1 (1,5) 1 (2) 0 0 CDC V 2 (3) 2 (4) 0 0 Readmissions 5 (7,5) 4 (8) 1 (9) 0 0.8 Postoperative Instillation therapy Mitomycin BCG 26 (39) 1 (1,5) 25 (50) 1 (2) 0 0 1 (20) 0 Local recurrence 1 (1,5) 1 (2) 0 0 Bladder Recurrence 6 (9) 5 (10) 0 1 (20) Distant metastasis 4 (6,6) 1 (2) 3 (27) 0 Follow up (Month), mean 25.9 24.5 28.5 33.8 0.5 Cancer related death 3 (4,5) 2 (4) 1 (9) 0 Death to other reasons 1 (1,5) 1 (2) 0 0 The 2 year Recurrence free survival 56 (84,4) 43 (86) 8 (72,7) 5 (100) 0.25 The 2 year Cancer specific survival 63 (95,4) 48 (96) 10 (91) 5 (100) 0.5 The 2 year Overall survival 62 (94 ) 48 (96) 9 (82) 5 (100) 0.6 CD: Clavien-Dindo, BCG: Bacillus Calmette–Guérin, Categorical data are presented as numbers %. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2024 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 16 Aug, 2024 Reviews received at journal 15 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviews received at journal 06 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers invited by journal 29 Jul, 2024 Editor invited by journal 10 Jun, 2024 Editor assigned by journal 10 Jun, 2024 Submission checks completed at journal 10 Jun, 2024 First submitted to journal 31 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4511142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":313933496,"identity":"f1cd1c1c-5863-4f6e-b0c1-2848a51781ae","order_by":0,"name":"Mahmoud Farzat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYFACHhDBzA/hVFjwEK1FsgFEHTgjQaqWg20ShDXotp89uuFjm7UE/+zjDz9/nCchY3C8gfHDxxzcWszO5KXdnNmWLiFxLiFZ4uA2CR6DMweYJWduw6PlQI7Zbd62w3UMZxgOgLVIzkhgY+bFp+X8G7AWCfkzjM0/Ds4Bapn/gICWGxBbJAzOMLNJHGyQ4OGXYCCk5Y3ZzRnn0iUMz7CxWZw5BtTCk9iM3y/nc8xufCizlpA7w/74RkWNjT0b++GDHz7i0YINMDaQpn4UjIJRMApGAQYAAGISUGxnIX1qAAAAAElFTkSuQmCC","orcid":"","institution":"Justus-Liebig University of Giessen","correspondingAuthor":true,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Farzat","suffix":""},{"id":313933497,"identity":"b5c77050-094e-45e7-986c-4f86dfa3a703","order_by":1,"name":"Sami-Ramzi Leyh-Bannurah","email":"","orcid":"","institution":"Martini Clinic, Prostate Cancer Center at University Hospital Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Sami-Ramzi","middleName":"","lastName":"Leyh-Bannurah","suffix":""},{"id":313933498,"identity":"de9d1f22-a7bd-4e32-a0db-45bf52a4f56f","order_by":2,"name":"Florian M. Wagenlehner","email":"","orcid":"","institution":"Martini Clinic, Prostate Cancer Center at University Hospital Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Florian","middleName":"M.","lastName":"Wagenlehner","suffix":""}],"badges":[],"createdAt":"2024-05-31 21:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4511142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4511142/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-024-01629-y","type":"published","date":"2024-11-01T16:20:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68207280,"identity":"a8149652-0fbc-4835-9872-c923bc50c13b","added_by":"auto","created_at":"2024-11-04 16:36:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":617093,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4511142/v1/282379fb-db3d-4a31-9cb0-b8f23aac5c05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic Surgery of the Urothelial Carcinoma of the Upper Urinary Tract Single Surgeon Initial Experience, 66 consecutive cases","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eUpper urinary tract carcinoma (UTUC) accounts for approximately 7% of all urothelial cancers (1). Previous series mostly focused on either comparison between open versus laparoscopic radical nephroureterectomy (LNU) (2, 3) (4) or laparoscopic versus robotic nephroureterectomy (RANU) (5) (6-8). Since LNU is a challenging procedure concerning bladder cuff excision, many surgeons tended to combine the laparoscopic approach with an open ureterectomy (9). However, Peyronnet et al. suggested that oncological outcomes of LNU may be less favorable than those of open radical nephroureterectomy (RNU) when the bladder cuff is excised laparoscopically, particularly in patients with locally advanced high-risk tumors (4). Also, the impact of lymphadenectomy (LAD) on clinical outcomes during radical nephroureterectomy (RNU) was also investigated by various authors (10-12). For example, Yoo et al. found that LAD may impact the 5-year recurrence-free survival (13). In consequence, a lymphadenectomy should be ideally performed during RNU. Second, in patients with low-risk / low-grade and noninvasive UTUC a kidney-sparing approach represents an important therapeutic option (14). In this context, the robot-assisted approach might mitigate potential disadvantages of the laparoscopic approach and provide a solution for adequate oncological outcomes, sufficient lymphadenectomy and kidney sparing in select patients. Data is still very limited, but RANU is increasingly utilized in the surgery of UTUC (15, 16). For example, Yajima et al. reported a case of simultaneous RANU with robot-assisted radical cystectomy (RARC)(17). Thus, we investigated the complications and oncological outcomes of robot-assisted radical nephroureterectomy (RANU) and robot-assisted segmental ureterectomy (RASU) patients in a referral urological department performed by a single robotic expert surgeon.\u003c/p\u003e"},{"header":"2.\tMethods ","content":"\u003cp\u003eWe performed 66 consecutive procedures transperitoneally with the Da Vinci X\u0026reg; Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Surgeries were performed by a single robotic-expert surgeon with a caseload of over 2000 combined robotic procedures. Hilar, paraaortic, retrocaval and interaortocaval lymphadenectomy was performed in kidney pelvis tumor cases, in which lymph nodes were deemed suspicious on preoperative CT scans or when tumours met high-risk criteria according to EAU guidelines for UTUC\u0026nbsp;(1). In case of high-risk ureteral urothelial cancers, the iliac lymph nodes were removed. Group 1 was defined as RANU patients. They also received a bladder cuff excision, and no drain was inserted. Group 2 was defined as RANU patients with simultaneous RARC. In those, the resected kidney was removed in an en-bloc approach with the bladder and a drain was inserted in this group. Group 3 was defined as RASU patients, i.e. distal ureterectomy, who received a catheter insertion and a bladder closure. These patients did not receive any drains. In group 1 and 3, a cystography was performed on third day after surgery. When cystography was uneventful, patients received mitomycin and the catheter was removed. \u0026nbsp;Overall, 66 patients underwent RANU and RASU between July 2019 and December 2023. We compared demographic and perioperative parameters between groups. Postoperative complications were graded using the Clavien-Dindo classification(18). Follow-ups were performed regularly according to EAU guidelines(1).\u003c/p\u003e\n\u003cp\u003eData was collected prospectively in an institutional database and analyzed with SPSS\u0026reg; v27. Categorical variables were presented as frequencies, while continuous variables were presented as mean values. Kolmogorov-Smirnov test verified normal distribution. Independent T-test and Mann-Whitney U test were used for matched-pair analysis of parametric and non-parametric variables, respectively. Pearson\u0026apos;s chi-square test was used to compare relative frequencies. For parametric numeric variables, a one-way ANOVA test was performed, followed by a post hoc comparison (Bonferroni) test if needed. The independent samples Kruskal-Wallis test was used for nonparametric variables.\u003c/p\u003e\n\u003cp\u003eThe study was conducted under the ethical standards of the Declaration of Helsinki and approved by the ethics committees of the medical association Westfalen-Lippe and Wilhelm\u0026rsquo;s University of Muenster (2023-500-f-S).\u003cdel cite=\"mailto:mahmoud%20farzat\" datetime=\"2024-06-04T20:47\"\u003e\u0026nbsp; \u0026nbsp;\u003c/del\u003e\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Parameters\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients were grouped according to surgical procedure they received for UTUC treatment (Table 1). Group 1 had 50 patients who underwent RANU, Group 2 had 11 patients who had RANU simultaneously with RARC, and Group 3 had 5 patients who underwent RASU. Overall, patients\u0026rsquo; mean age was 71 years with similar distribution among groups (p=0.7). Their average BMI was 31 with no variation among groups (p=0.9). 45% of patients were classified as ASA 3 with no statistical differences observed among groups (p=0.38). Group 2 patients had confirmed preoperative histological tumors, while only 20% in group 1 did (p=0.014). Hence in group 1, surgery was also based on clinical and radiographic diagnosis, even with negative or equivocal endourological biopsy results. Group 2 had the most advanced tumours, with 80% of them being at least clinical T2 tumors (p=0.014). Group 1 had the highest intake of anti-coagulation medication, with 15 (33%) patients taking aspirin (p=0.003). \u0026nbsp;Overall, n=8/66 (12%) patients received neoadjuvant platin-based chemotherapy. All other study parameters were similar between the groups. Further details are given in Table 1. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntra- and perioperative data:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, the average console time was 63 minutes (Table 2). Group 2 patients, who received RANU simultaneous with RARC, had the shortest time at 42 minutes for the RANU procedure vs. the longest time in RASU patients at 73 minutes (p=0.065 ). Overall, 38% of patients had locally advanced carcinomas and statistical analysis showed no significant difference for tumor stage between groups (p=0.18). 62% of patients had high-risk carcinomas \u0026nbsp;(p=0.3), and only one patient in the study had a positive surgical margin. Among those, who received a LAD (n=20), the mean number of lymph nodes removed was 13.7, with a maximum mean number of 22 in group 2, (p=0.035). In the same group of those, who received a LAD, 6 (33%) were positive for LN metastases. The mean hospital stay for all patients was 8.1 days, with the longest stay in group 2 at 10 days, which was statistically significantly longer compared to other study groups \u0026nbsp;(p=0.4). Overall, 6 out of 66 patients (9%) received a perioperative blood transfusion, with no significant difference between the study groups (p=0.6). More details in table 2. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGroup 2 Patients (36%) had more complications than group 1 (24%) und group 3 (0%) (p=0.04). Overall 5/66 patients (8%) were readmitted within 90 days after discharge. The statistical analysis showed no difference between groups (p=0.8). The most common major complication we observed, was 4 incisional hernias on the mini-laparotomy site, that was used to extract the specimen. One female patient developed an embolus of the arteria iliaca externa and had to undergo an emergency embolectomy. One 90-year-old male patient experienced bleeding on the first operative day with a hemoglobin decrease of more than 6 g/dl after an uneventful intraoperative course. One male patient had a diagnostic laparascopy due to suspicion of mechanical bowel obstruction, which was not confirmed, and resolved thereafter after further medical bowel stimulation. The final complication was wound infection which necessitated wound revision and a superficial Vacuum-assisted closure system. The surgery-related mortality rate at 3 months in our cohort was 3%; n=2/66. Specifically, two geriatric patients over 80 years old received palliative surgery due to persistent macrohematuria, refractory to endosurgical treatments. Of those, the first, female patient died due to cardiac decompensation. The second, male patient had a hostile abdomen due to previous surgeries, underwent bowel adhesiolysis and bowel resection, before the robot-assisted nephroureterectomy and later died due to multiorgan insufficiency. \u0026nbsp;More details in table 3. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOncological Results:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn group 1, in 10% of patients, a tumor could not be detected in the final pathology. Of those, 2 patients had neoadjuvant chemotherapy, 2 patients had highly suspicious tumor findings in the multiphase contrast enhanced CT-Scan and one young, 42 year old, male patient had endoscopically proven ureteral cancer. Postoperatively, n=26/50 (52%) patients received mitomycin. 5 patients received adjuvant platin-based chemotherapy while 3 patients received checkpoint inhibitors. The median follow-up in our series is 26 months (interquartile range from 9 to 43 months). One patient with locally advanced UTUC had local recurrence at the kidney site, while 6 (9%) patients had bladder recurrence and 4 (6%) patients had distant metastasis. We recorded 3/66 (4,5%) cancer-related deaths and 1 (1,5%) death due to other reasons. The recurrence-free survival in our study was 84,4% at 24 months. While the cancer-specific survival was 95% at 24 months, the overall survival was virtually identical at 94% at 24 months. Details are given in table 3.\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWith the increased adoption of robotic surgery in the treatment of urothelial malignancies including UTUC, the vast majority of related literature focused on the comparison between the different surgical approaches and their results in context of UTUC(2-4). Some surgeons combined different approaches, such as laparascopy and open surgery with robot-assisted surgery to gain the best possible results(6) (9). Some investigated the potential benefit of LAD during nephroureterectomy(10). However, to this date, previous series are very sparse and mostly limited due to small sample sizes and/or still maturing surgical expertise. For example, the multicenter study by Campi et al. relied on a total combined cohort of 81, with a highly variable robotic caseload(19). Moreover, similar to RARC patients UTUC patients represent a highly variable patient cohort, young and fit patients vs. senior patients with high comorbidity burden and previous surgical interventions(20). Thus, we relied on a real world cohort without strict selection criteria with an adequate sample size and a single robotic-surgeon expert with a combined caseload of over 2000 combined robotic procedures (i.e RARP, RARCs and complete or partial nephrectomies). This is reflected by three different robot-assisted surgical methods, RANU, combined RANU in en-bloc fashion and RASU. Moreover, we relied on comprehensive results, i.e. intra- and perioperative data including complications and oncological follow-up. \u0026nbsp;Our study had important findings. \u003cins cite=\"mailto:Leyh-Bannurah,%20Sami-Ramzi\" datetime=\"2024-03-29T21:07\"\u003e\u0026nbsp;\u003c/ins\u003e\u003c/p\u003e\n\u003cp\u003eFirst, mean age of 71, a mean BMI of 31 that denotes obese patients and a majority of ASA3 status proportion overall indicate a challenging, but real-life patient cohort. Similarly, tumor characteristics are reflected in the careful choice of surgery approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecond, it is important to note that in our real-world cohort, 10% of patients could benefit from a kidney-sparing (i.e. RASU) approach if tumor localization and size were carefully considered. In 11 out of 66 cases (16%) with an aggressive, muscle-invasive bladder carcinoma accompanied by UTUC, a combined RANU and RARC procedure was found to be feasible. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThird, our intra- and perioperative characteristics indicate rather short surgical times and low Clavien-Dindo Complication (CDC) rates, demonstrating that the robot-assisted UTUC surgery is particularly suited with respect to perioperative morbidity for a comorbidity-burdened patient cohort. The surgical efficiency and outcomes might be attributed to two aspects. First, the surgical experience of almost 2000 robotic procedures, which is considered a super-expert (21, 22) and second, the single docking of the robot, i.e. no repositioning of the patient and no re-docking during the procedure. This notion and corresponding causality is supported by Yajima et al., who reported the first case of combined RANU and RARC in Japan. They reported RANU console time to be 66 (RANU) and 207 (RARC) \u0026thinsp;minutes which is in accordance with our findings (42 minutes for RANU in group 2)(17). Moreover, Kamei et al. compared the en-bloc cystectomy with radical nephroureterectomy between 17 open-surgical and 10 robot-assisted patients and found the minimally invasive approach to be non-inferior (23). These findings clearly demonstrate the need to include surgical expertise in analyzing results of such robot-assisted surgeries as in our study at hand, going hand-in-hand with the en-bloc approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFourth, in the study at hand technical feasibility included LAD, which prognostic impact remains of great debate. For example, Inokuchi et al. reported simultaneous LAD, with consistent mean LAD yield compared to our study(10). Specifically, Dominguez-Escrig et al. reported that template-based and complete lymph node dissection improves cancer-specific survival (CSS) in patients with high-stage UTUC and reduces the risk of local recurrence\u0026nbsp;(11). Thus, a LAD remains an important cornerstone in UTUC surgery. The number of removed lymph nodes ranged between 5,5 and 21\u0026nbsp;(5, 13). Yoo et al. found that 12.1% who underwent lymph node dissection, had pathological lymph node metastasis in their final pathology\u0026nbsp;(13). Similarly, De Groote et. al performed LAD in 41% of patients and found lymph node involvement in 29%\u0026nbsp;(15). In our study, the mean number of removed lymph nodes was 13.7 similar to other publications(5)\u0026nbsp;(13). Furthermore, we performed LAD only in high-risk patients and or when suspicion was given in a CT scan preoperatively. Similarly, we found metastasis in 33% of patients, who underwent LAD. Taken together, our findings are consistent with previous series and demonstrate that LAD during RANU with or without RARC is highly feasible.\u003c/p\u003e\n\u003cp\u003eFifth, despite high comorbidity burden our cohort experienced an overall major complication rate (i.e. CDC III a or higher) of 17%. These results are lower than reported by other surgeons (5, 6, 15). However, we did not yet apply the most recent Comprehensive Complication Index (CCI\u0026reg;) introduced by Slankamenac, adopted for open radical cystectomy by Vetterlein et. al and first adopted by Mendrek et al. for RARC(24-26). Such new metrics will enable better comparison between centres, patient counselling and enable greater granularity for such complex surgery as in our current study. Interestingly, the readmission rate was relatively low at 7.5%, compared to 8.2% reported by Liedberg et al(27).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixth, in our study, 9% of patients had bladder recurrence and 6% had distant metastasis. These findings are highly consistent with open UTUC series. Hemal et al. found no local recurrence in their series of 48 patients (9). In our study, we observed one local recurrence at the kidney site. However, in the study conducted by Hemal et al., almost 10% of patients in both arms experienced bladder recurrence and distant metastases. The authors reported the 5-year recurrence-free survival, cancer-free and overall survival in their laparoscopic LNU arm to be 90,4% , 95,2% and 85,7% respectively (9). Campi et al. reported 20% ipsilateral upper tract recurrence after RASU, and 7.5% distant metastases after RANU (19). We reported our data with mean follow-up of 28 months. While the Recurrence-free survival at a median follow up of 26 months in our study was 84,4%, our patients had similar cancer-specific 95,4% and superior overall survival at 94%. \u0026nbsp;De Groote et al. found 4-year Overall survival (OS) of 66% and recurrence-free survival (RFS) and 53% at a median follow-up of 15 months (15). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, our study mortality rate at 24 months is 3% (2/66) patients. Our rate is higher than what has been reported by others (20). However, it is of note that our data relies on a real-life cohort and that the large confidence interval is not suited for comparability. Moreover, this could be attributed to the extensive comorbidities in some of our patients. Another reason could be that a significant portion of our patients underwent surgery in almost palliative symptomatic settings due to persistent uncontrolled macrohematuria. Seisen et al. proposed, in their systematic review dealing with the safety of kidney-sparing surgery (KSS) for UTUC and comparing it to RANU, similar survival after Kidney sparing surgery (KSS) versus RANU only for low-grade and noninvasive UTUC when using endourological interventions (14). In our study, only 5 out of 55 patients (10%) were suitable candidates for RASU. Among these patients, two had high-stage tumours, T2 and T3. This finding is consistent with Seisen and colleagues\u0026rsquo; suggestion that selected patients with high-grade and invasive upper tract urothelial carcinoma (UTUC) could benefit safely from this type of surgery when feasible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut study has limitations. Our analyses were performed retrospectively. To ensure the study reflected real-world scenarios, all consecutive patients from aforementioned three treatment groups were included, representing different UTUC procedures. Nonetheless despite that sample size, in comparison, 66 cases in 4 years in one center is indiciates a higher number for a single center compared to 78 cases over 10 years in 3 high volume robotic surgery centers (15). In consequence future series are necessary to confirm our findings. Specifically, our findings still serve as a proof of feasibility and proof of favorable patient outcomes. Thus, we anticipate further widespread adoption of the techniques reported in our study. Additionally, it\u0026rsquo;s worth noting that the study was conducted in a high-volume robotic tertiary center. Therefore the findings may not apply to other centers with different surgical focus or different caseloads .\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRobotic surgery is a viable treatment option for urothelial carcinoma of the upper urinary tract if performed by an experienced surgeon. It can be used flexibly depending on the surgical indication and the specific patient cohort. Prospective studies are warranted to confirm its proposed benefits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCDC: Clavien-Dindo Complication \u003c/p\u003e\n\u003cp\u003eUTUC: upper urinary tract carcinoma\u003c/p\u003e\n\u003cp\u003eRANU: robot-assisted radical nephroureterectomy\u003c/p\u003e\n\u003cp\u003eRARC: robot-assisted radical Cystectomy\u003c/p\u003e\n\u003cp\u003eRASU: robot-assisted segmental ureterectomy\u003c/p\u003e\n\u003cp\u003eUC: urothelial carcinoma\u003c/p\u003e\n\u003cp\u003eLNU: Laparoscopic radical nephroureterectomy\u003c/p\u003e\n\u003cp\u003eLAD: Lymphadenectomy \u003c/p\u003e\n\u003cp\u003eLN: Lymph nodes\u003c/p\u003e\n\u003cp\u003eAC anticoagulation\u003c/p\u003e\n\u003cp\u003eASA American association of anesthesiology score \u003c/p\u003e\n\u003cp\u003eBMI body mass index\u003c/p\u003e\n\u003cp\u003eHgb hemoglobin\u003c/p\u003e\n\u003cp\u003ePSM positive surgical margins\u003c/p\u003e\n\u003cp\u003eCCS cancer specific survival\u003c/p\u003e\n\u003cp\u003eRFS recurrence free survival\u003c/p\u003e\n\u003cp\u003eOS overall survival\u003c/p\u003e\n\u003cp\u003eBR bladder recurrence \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted under the ethical standards of the Declaration of Helsinki and approved by the ethics committees of the medical association Westfalen-Lippe and Wilhelm\u0026rsquo;s University of Muenster (2023-500-f-S) date 21.11.2023.The need for informed consent was waived by the ethic committees of the Medical Association Westfalen-Lippe and Wilhelm\u0026rsquo;s University of M\u0026uuml;nster (2023-500-f-S) date 21.11.2023\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicabl.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to national regulations on perosnal data protection but are available from the corresponding author on reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no conflicts of interest to disclose.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, M.F. and S. LB.; Methodology, M.F.; Software, M.F. ; Validation, M.F.; Formal analysis, M.F. ; Investigation, M.F.; Data curation, M.F.; Writing\u0026mdash;original draft M.F., S. LB. and F.W.; Writing\u0026mdash;review \u0026amp; editing, M.F. S. LB and F.M.W.; Visualization, M.F.; Supervision, M.F., S. LB. and F.M.W.; Project administration, M.F. and F.M.W.; Funding acquisition, not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoupr\u0026ecirc;t M, Seisen T, Birtle AJ, Capoun O, Comp\u0026eacute;rat EM, Dominguez-Escrig JL, et al. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update. Eur Urol. 2023;84(1):49-64.\u003c/li\u003e\n\u003cli\u003eRibal MJ, Huguet J, Alcaraz A. Oncologic outcomes obtained after laparoscopic, robotic and/or single port nephroureterectomy for upper urinary tract tumours. World J Urol. 2013;31(1):93-107.\u003c/li\u003e\n\u003cli\u003eRassweiler JJ, Schulze M, Marrero R, Frede T, Palou Redorta J, Bassi P. Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery? Eur Urol. 2004;46(6):690-7.\u003c/li\u003e\n\u003cli\u003ePeyronnet B, Seisen T, Dominguez-Escrig JL, Bruins HM, Yuan CY, Lam T, et al. Oncological Outcomes of Laparoscopic Nephroureterectomy Versus Open Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An European Association of Urology Guidelines Systematic Review. Eur Urol Focus. 2019;5(2):205-23.\u003c/li\u003e\n\u003cli\u003eMelquist JJ, Redrow G, Delacroix S, Park A, Faria EE, Karam JA, et al. Comparison of Single-docking Robotic-assisted and Traditional Laparoscopy for Retroperitoneal Lymph Node Dissection During Nephroureterectomy With Bladder Cuff Excision for Upper-tract Urothelial Carcinoma. Urology. 2016;87:216-23.\u003c/li\u003e\n\u003cli\u003eAmbani SN, Weizer AZ, Wolf JS, Jr., He C, Miller DC, Montgomery JS. Matched comparison of robotic vs laparoscopic nephroureterectomy: an initial experience. Urology. 2014;83(2):345-9.\u003c/li\u003e\n\u003cli\u003eJi R, He Z, Fang S, Yang W, Wei M, Dong J, et al. Robot-assisted vs. laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis based on comparative studies. Front Oncol. 2022;12:964256.\u003c/li\u003e\n\u003cli\u003eHuang YP, Huang EY, Chung HJ, Tai MC, Huang TH, Wei TC, et al. Is Robotic Superior to Laparoscopic Approach for Radical Nephroureterectomy with Bladder Cuff Excision in Treating Upper Urinary Tract Urothelial Carcinoma? J Endourol. 2023;37(2):139-46.\u003c/li\u003e\n\u003cli\u003eHemal AK, Kumar A, Gupta NP, Seth A. Retroperitoneal nephroureterectomy with excision of cuff of the bladder for upper urinary tract transitional cell carcinoma: comparison of laparoscopic and open surgery with long-term follow-up. World J Urol. 2008;26(4):381-6.\u003c/li\u003e\n\u003cli\u003eInokuchi J, Kuroiwa K, Kakehi Y, Sugimoto M, Tanigawa T, Fujimoto H, et al. Role of lymph node dissection during radical nephroureterectomy for upper urinary tract urothelial cancer: multi-institutional large retrospective study JCOG1110A. World J Urol. 2017;35(11):1737-44.\u003c/li\u003e\n\u003cli\u003eDominguez-Escrig JL, Peyronnet B, Seisen T, Bruins HM, Yuan CY, Babjuk M, et al. Potential Benefit of Lymph Node Dissection During Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the European Association of Urology Guidelines Panel on Non-muscle-invasive Bladder Cancer. Eur Urol Focus. 2019;5(2):224-41.\u003c/li\u003e\n\u003cli\u003eSeisen T, Shariat SF, Cussenot O, Peyronnet B, Renard-Penna R, Colin P, et al. Contemporary role of lymph node dissection at the time of radical nephroureterectomy for upper tract urothelial carcinoma. World J Urol. 2017;35(4):535-48.\u003c/li\u003e\n\u003cli\u003eYoo S, You D, Jeong IG, Hong B, Hong JH, Ahn H, et al. Does lymph node dissection during nephroureterectomy affect oncological outcomes in upper tract urothelial carcinoma patients without suspicious lymph node metastasis on preoperative imaging studies? World J Urol. 2017;35(4):665-73.\u003c/li\u003e\n\u003cli\u003eSeisen T, Peyronnet B, Dominguez-Escrig JL, Bruins HM, Yuan CY, Babjuk M, et al. Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel. Eur Urol. 2016;70(6):1052-68.\u003c/li\u003e\n\u003cli\u003eDe Groote R, Decaestecker K, Larcher A, Buelens S, De Bleser E, D\u0026apos;Hondt F, et al. Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: results from three high-volume robotic surgery institutions. J Robot Surg. 2020;14(1):211-9.\u003c/li\u003e\n\u003cli\u003eTrudeau V, Gandaglia G, Shiffmann J, Popa I, Shariat SF, Montorsi F, et al. Robot-assisted versus laparoscopic nephroureterectomy for upper-tract urothelial cancer: A population-based assessment of costs and perioperative outcomes. Can Urol Assoc J. 2014;8(9-10):E695-701.\u003c/li\u003e\n\u003cli\u003eYajima S, Nakanishi Y, Yasujima R, Hirose K, Sekiya K, Umino Y, et al. Simultaneous robot-assisted nephroureterectomy and radical cystectomy. IJU Case Rep. 2023;6(1):14-7.\u003c/li\u003e\n\u003cli\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-96.\u003c/li\u003e\n\u003cli\u003eCampi R, Cotte J, Sessa F, Seisen T, Tellini R, Amparore D, et al. Robotic radical nephroureterectomy and segmental ureterectomy for upper tract urothelial carcinoma: a multi-institutional experience. World J Urol. 2019;37(11):2303-11.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Sullivan NJ, Naughton A, Temperley HC, Casey RG. Robotic-assisted versus laparoscopic nephroureterectomy; a systematic review and meta-analysis. BJUI Compass. 2023;4(3):246-55.\u003c/li\u003e\n\u003cli\u003eHung AJ, Oh PJ, Chen J, Ghodoussipour S, Lane C, Jarc A, et al. Experts vs super-experts: differences in automated performance metrics and clinical outcomes for robot-assisted radical prostatectomy. BJU Int. 2019;123(5):861-8.\u003c/li\u003e\n\u003cli\u003eHung AJ, Chen J, Jarc A, Hatcher D, Djaladat H, Gill IS. Development and Validation of Objective Performance Metrics for Robot-Assisted Radical Prostatectomy: A Pilot Study. J Urol. 2018;199(1):296-304.\u003c/li\u003e\n\u003cli\u003eKamei J, Fujisaki A, Saito K, Sugihara T, Ando S, Miyagawa T, et al. Less invasive and equivalent short-term outcomes with simultaneous en bloc robot-assisted radical cystectomy and laparoscopic nephroureterectomy: Comparison with conventional open radical cystectomy and nephroureterectomy. Asian J Endosc Surg. 2022;15(2):255-60.\u003c/li\u003e\n\u003cli\u003eSlankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258(1):1-7.\u003c/li\u003e\n\u003cli\u003eVetterlein MW, Klemm J, Gild P, Bradtke M, Soave A, Dahlem R, et al. Improving Estimates of Perioperative Morbidity After Radical Cystectomy Using the European Association of Urology Quality Criteria for Standardized Reporting and Introducing the Comprehensive Complication Index. Eur Urol. 2020;77(1):55-65.\u003c/li\u003e\n\u003cli\u003eMendrek M, Witt JH, Sarychev S, Liakos N, Addali M, Wagner C, et al. Reporting and grading of complications for intracorporeal robot-assisted radical cystectomy: an in-depth short-term morbidity assessment using the novel Comprehensive Complication Index(\u0026reg;). World J Urol. 2022;40(7):1679-88.\u003c/li\u003e\n\u003cli\u003eLiedberg F, Abrahamsson J, Bobjer J, Gudjonsson S, L\u0026ouml;fgren A, Nyberg M, et al. Robot-assisted nephroureterectomy for upper tract urothelial carcinoma-feasibility and complications: a single center experience. Scand J Urol. 2022;56(4):301-7. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Analysis of demographic and baseline characteristics:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUTUC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(N=66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGroup 1\u003c/p\u003e\n \u003cp\u003eRANU\u003c/p\u003e\n \u003cp\u003eN=50 (77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGroup 2\u003c/p\u003e\n \u003cp\u003eCombined RANU\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;and RARC\u003c/p\u003e\n \u003cp\u003eN=11 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eGroup 3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eRobot-assisted\u0026nbsp;\u003c/p\u003e\n \u003cp\u003esegmental\u003c/p\u003e\n \u003cp\u003eUreterectomy\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eN= 5 (7,6%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep-Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge (years), mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e), mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eASA-score\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (30)\u003c/p\u003e\n \u003cp\u003e16 (24)\u003c/p\u003e\n \u003cp\u003e30 (45,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (28)\u003c/p\u003e\n \u003cp\u003e11 (22)\u003c/p\u003e\n \u003cp\u003e25 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (45)\u003c/p\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e2 (40)\u003c/p\u003e\n \u003cp\u003e2 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative Hgb (g/dl), mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTumor location\u003c/p\u003e\n \u003cp\u003eIntramural ureter\u003c/p\u003e\n \u003cp\u003eOther parts of Ureter\u003c/p\u003e\n \u003cp\u003eKidney pelvis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMultifocal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (18)\u003c/p\u003e\n \u003cp\u003e18 (27)\u003c/p\u003e\n \u003cp\u003e34 (51)\u003c/p\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (6)\u003c/p\u003e\n \u003cp\u003e12 (24)\u003c/p\u003e\n \u003cp\u003e33 (66)\u003c/p\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (81)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative Histology\u003c/p\u003e\n \u003cp\u003eNo Histology\u003c/p\u003e\n \u003cp\u003eTis\u003c/p\u003e\n \u003cp\u003eTa\u003c/p\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44 (66)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003cp\u003e11 (16)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003cp\u003e8 (12)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40 (80)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e9 (18)\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e8 (72)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (80)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.014\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeoadjuvant Chemotherapy\u003c/p\u003e\n \u003cp\u003e2 cycles cisplatin-Gemcitabine\u003c/p\u003e\n \u003cp\u003e3 cycles cisplatin-Gemcitabine\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 cycles cisplatin-Gemcitabine\u003c/p\u003e\n \u003cp\u003e6 cycles cisplatin-Gemcitabine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003cp\u003e3 (4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnti-coagulation\u003c/p\u003e\n \u003cp\u003eAspirin\u003c/p\u003e\n \u003cp\u003eNOAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e19 (13,6)\u003c/p\u003e\n \u003cp\u003e6 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e15 (30)\u003c/p\u003e\n \u003cp\u003e3 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e3 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.003\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime from first diagnosis to procedure\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(months), mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCategorical data are presented as numbers %, UTUC: Upper Urinary Tract Urothelial Cell Carcinoma, \u0026nbsp; RANU: robot-assisted nephroureterctomy, RARC: robot-assisted radical cystectomy. BMI: body mass index, ASA: American Association of Anesthesiology Morbidity Score, Hgb: hemoglobin, NOAC: new oral anticoagulants, \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Intra- and postoperative data and pathological findings between groups:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eUTUC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003eTotal (N=66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003eGroup 1\u003c/p\u003e\n \u003cp\u003eRANU\u003c/p\u003e\n \u003cp\u003eN=50 (77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003eGroup 2\u003c/p\u003e\n \u003cp\u003eCombined RANU\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;and RARC\u003c/p\u003e\n \u003cp\u003eN=11 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eGroup 3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eRobot-assisted\u0026nbsp;\u003c/p\u003e\n \u003cp\u003esegmental\u003c/p\u003e\n \u003cp\u003eUreterectomy\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eN= 5 (7,6%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eConsole time (minute), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e63 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e69 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e42 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e73 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003ePathological tumor stage, n (%)*\u003c/p\u003e\n \u003cp\u003epT0\u003c/p\u003e\n \u003cp\u003epTa\u003c/p\u003e\n \u003cp\u003epT1\u003c/p\u003e\n \u003cp\u003epT2\u003c/p\u003e\n \u003cp\u003epT3\u003c/p\u003e\n \u003cp\u003epT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (7,5)\u003c/p\u003e\n \u003cp\u003e11 (16)\u003c/p\u003e\n \u003cp\u003e12 (18)\u003c/p\u003e\n \u003cp\u003e13 (19,6)\u003c/p\u003e\n \u003cp\u003e21 (32)\u003c/p\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003cp\u003e9 (18)\u003c/p\u003e\n \u003cp\u003e11 (22)\u003c/p\u003e\n \u003cp\u003e10 (20)\u003c/p\u003e\n \u003cp\u003e15 (30)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e5 (45)\u003c/p\u003e\n \u003cp\u003e4 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2 (40)\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eUrothelial carcinoma grade*, n (%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (7,5)\u003c/p\u003e\n \u003cp\u003e14 (21)\u003c/p\u003e\n \u003cp\u003e5 (7,5)\u003c/p\u003e\n \u003cp\u003e41 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003cp\u003e11 (22)\u003c/p\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003cp\u003e29 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e11 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e3 (60)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative Chemotherapy\u003c/p\u003e\n \u003cp\u003e(yes. vs. none), n (%)\u003c/p\u003e\n \u003cp\u003e2 cycles cisplatin-Gemcitabine, n (%)\u003c/p\u003e\n \u003cp\u003e3 cycles cisplatin-Gemcitabine, n (%)\u003c/p\u003e\n \u003cp\u003e4 cycles cisplatin-Gemcitabine, n (%)\u003c/p\u003e\n \u003cp\u003e6 cycles cisplatin-Gemcitabine, n (%)\u003c/p\u003e\n \u003cp\u003eInitiation of CI therapy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003cp\u003e3 (4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003ePositive surgical margins (total), (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of patients, who received a lymphadenectomy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e20 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e10 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e9 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of lymph nodes removed in patients, who received a lymphadenectomy, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e13.7 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e7 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e22 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of patients, who had a lymphadenectomy and had metastases among the total number of surgically treated patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e6/20 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e1/10 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e5/9 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e0/1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eLength of hospitalization (days), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e8.1 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e7.9 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e10 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e5.8 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53136531365314%\" valign=\"top\"\u003e\n \u003cp\u003eTransfusion rate, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.96309963099631%\" valign=\"top\"\u003e\n \u003cp\u003e6 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.837638376383763%\" valign=\"top\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.391143911439114%\" valign=\"top\"\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.682656826568266%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.59409594095941%\" valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* patients with multiple tumours: the most significant cancer was listed, Categorical data are presented as numbers %, UTUC: Upper Urinary Tract Urothelial Cell Carcinoma, \u0026nbsp;RANU: robot-assisted nephroureterctomy, RARC: robot-assisted radical cystectomy. SD: standard deviation, CI: Check point inhibitor, * Grade according to WHO classification 1999 (Busch et al.)[Busch, 2002 #251]\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Complications, readmissions and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eoncological long term results\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eamong study groups, Follow up time-lapse 3-48 Months\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"533\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eUTUC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGroup 1\u003c/p\u003e\n \u003cp\u003eRANU\u003c/p\u003e\n \u003cp\u003eN=50 (77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGroup 2\u003c/p\u003e\n \u003cp\u003eCombined RANU\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;and RARC\u003c/p\u003e\n \u003cp\u003eN=11 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eGroup 3\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eRobot-assisted\u0026nbsp;\u003c/p\u003e\n \u003cp\u003esegmental\u003c/p\u003e\n \u003cp\u003eUreterectomy\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eN= 5 (7,6%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003etotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.04\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMinor\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC I\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.78076062639821%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC II\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.093959731543624%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.765100671140939%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.01565995525727%\" valign=\"top\"\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.344519015659955%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMajor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC IIIa\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.78076062639821%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC III b\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.093959731543624%\" valign=\"top\"\u003e\n \u003cp\u003e7 (10,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.765100671140939%\" valign=\"top\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.01565995525727%\" valign=\"top\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.344519015659955%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.78076062639821%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC VI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.093959731543624%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.765100671140939%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.01565995525727%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.344519015659955%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.78076062639821%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;CDC V\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.093959731543624%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.765100671140939%\" valign=\"top\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.01565995525727%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.344519015659955%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003eReadmissions\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (7,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003cp\u003eInstillation therapy\u003c/p\u003e\n \u003cp\u003eMitomycin\u003c/p\u003e\n \u003cp\u003eBCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (39)\u003c/p\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (50)\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLocal recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eBladder Recurrence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDistant metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (6,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFollow up (Month), mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCancer related death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDeath to other reasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eThe 2 year Recurrence free survival \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (84,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (72,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eThe 2 year Cancer specific survival\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63 (95,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eThe 2 year Overall survival \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62 (94 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCD: Clavien-Dindo, BCG: Bacillus Calmette\u0026ndash;Gu\u0026eacute;rin, Categorical data are presented as numbers %.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"upper urinary tract carcinoma (UTUC), RANU, RARC, segmental ureterectomy","lastPublishedDoi":"10.21203/rs.3.rs-4511142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4511142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u0026nbsp;\u003c/strong\u003eRobotic surgery is increasingly utilized in the treatment of urothelial carcinoma of the upper urinary tract (UTUC). This study investigates the advantages and burden of robot-assisted surgical treatment of the urothelial carcinoma of the upper urinary tract in a referral urological department, along with their functional and oncological results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The study included 66 prospectively enrolled patients who were surgically treated by a single, robotically specialized surgeon between July 2019 and December 2023. Patients were divided into three groups. Group 1: 50 patients underwent robot-assisted radical Nephroureterectomy (RANU) with bladder cuff excision, Group 2: 11 patients underwent RANU simultaneously with robot-assisted radical cystectomy (RARC), and Group 3: 5 patients underwent robot-assisted segmental ureterectomy (RASU). Clinical and oncological parameters were compared. Perioperative morbidity according to Clavien-Dindo was the primary endpoint of our study. The secondary endpoint was oncologic outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e37.8% of patients had locally advanced carcinomas. The average console time of RANU with bladder cuff excision was 69 minutes. The rate of positive surgical margins was n=1/66 (2%). Lymphadenectomy (LAD) was performed on 30% of patients, with a mean of 13.7 lymph nodes removed. Of those who received LAD, 33% had lymph node metastasis. n=6/66 (9%) patients received blood transfusion. The overall complication rate was 24%. The readmission rate was 7.5%. With a median follow-up of 26 months, the 2-year recurrence-free survival rate was 84.4%, and the 2-year overall survival rate was 94%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eRobotic surgery is a feasible option for treating UTUC that can be adapted to meet the surgical needs of each patient. Prospective studies are warranted to confirm its benefits.\u003c/p\u003e","manuscriptTitle":"Robotic Surgery of the Urothelial Carcinoma of the Upper Urinary Tract Single Surgeon Initial Experience, 66 consecutive cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 07:44:52","doi":"10.21203/rs.3.rs-4511142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-16T14:01:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-15T16:00:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132073852571278190884660392112899146955","date":"2024-08-07T12:20:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-06T18:17:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300192916327888456275018958941443082413","date":"2024-08-06T17:59:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-29T09:45:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-10T15:07:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-10T15:05:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-10T15:05:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-05-31T21:52:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8f832a11-3755-4b7e-aae8-a45fa06dedf4","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:27:40+00:00","versionOfRecord":{"articleIdentity":"rs-4511142","link":"https://doi.org/10.1186/s12894-024-01629-y","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2024-11-01 16:20:25","publishedOnDateReadable":"November 1st, 2024"},"versionCreatedAt":"2024-06-25 07:44:52","video":"","vorDoi":"10.1186/s12894-024-01629-y","vorDoiUrl":"https://doi.org/10.1186/s12894-024-01629-y","workflowStages":[]},"version":"v1","identity":"rs-4511142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4511142","identity":"rs-4511142","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}