Single-Position Versus Traditional Retroperitoneal Laparoscopic Nephroureterectomy for UTUC: Long-Term Survival and Perioperative Outcomes

Single-Position Versus Traditional Retroperitoneal Laparoscopic Nephroureterectomy for UTUC: Long-Term Survival and Perioperative Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Position Versus Traditional Retroperitoneal Laparoscopic Nephroureterectomy for UTUC: Long-Term Survival and Perioperative Outcomes Kai Zhao, Jiao Huang, Yuxuan He, Bin Dong, Rui Zhang, Zongliang Zhang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8217690/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2026 Read the published version in BMC Urology → Version 1 posted 14 You are reading this latest preprint version Abstract Background: Traditional retroperitoneal laparoscopic radical nephroureterectomy (TRLRNU) for upper tract urothelial carcinoma (UTUC) requires intraoperative repositioning, increasing operative time and risk. A modified single-position approach (SRLRNU) may improve perioperative efficiency. Methods: We retrospectively analyzed 276 UTUC patients who underwent either SRLRNU (n = 131) or TRLRNU (n = 145) from 2020 to 2024. In SRLRNU, patients remained in a fixed oblique lateral decubitus position throughout, enabling complete nephroureterectomy and bladder cuff excision without repositioning. Detailed surgical steps and port configurations were standardized and are presented in this study. Perioperative and oncologic outcomes were compared between groups. Survival analyses were conducted using Kaplan–Meier and Cox regression models. Subgroup analyses were performed according to tumor stage and pathological characteristics. Results: The SRLRNU group showed significantly shorter operative time (124.47 ± 42.54 min vs 160.11 ± 51.43 min, p < 0.001) and reduced blood loss (47.61 ± 140.75 ml vs 71.45 ± 108.42 ml, p 0.05). Univariable and multivariable analysis suggested T stage, age, and ASA score as independent predictors of OS in the SRLRNU group. Hypoalbuminemia was significantly less frequent in the SRLRNU group (60.31% vs 77.24%, p = 0.002). Conclusion: SRLRNU is a safe and effective alternative to TRLRNU, offering improved perioperative outcomes without compromising long-term cancer control in UTUC patients. UTUC nephroureterectomy retroperitoneal laparoscopy single-position technique surgical optimization Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Upper tract urothelial carcinoma (UTUC) is a relatively rare malignancy, accounting for 5–10% of all urothelial cancers, but its incidence has been increasing in recent years, particularly in East Asia [1]. Radical nephroureterectomy (RNU) with bladder cuff excision remains the gold standard for managing high-risk UTUC according to international guidelines [2]. Laparoscopic approaches to RNU have gained popularity due to reduced morbidity and faster recovery compared to open surgery [3,4,5]. Among them, the retroperitoneal laparoscopic technique is favored for its direct access to the kidney and ureter, avoidance of bowel interference, and potential reduction in postoperative complications [6,7]. However, the traditional retroperitoneal approach (TRLRNU) typically requires intraoperative repositioning, from lateral decubitus to lithotomy, to facilitate bladder cuff excision, which increases operative time, complexity, and infection risk [8,9]. To overcome these limitations, a single-position retroperitoneal laparoscopic radical nephroureterectomy (SRLRNU) technique has been introduced. By maintaining the patient in a single lateral decubitus position throughout the procedure, SRLRNU aims to streamline surgical workflow and potentially improve perioperative outcomes. Despite its increasing adoption in clinical practice, evidence comparing the safety, feasibility, and oncologic equivalence of SRLRNU and TRLRNU remains limited [10]. In this study, detailed surgical steps and port configurations of SRLRNU were optimized and presented. We sought to compare the perioperative and oncologic outcomes of SRLRNU and TRLRNU in patients with UTUC. We aimed to determine whether SRLRNU could offer improved intraoperative efficiency without compromising long-term survival, thereby supporting its broader application in routine urologic oncology practice. Patients and Methods Study design This retrospective cohort study included 276 patients diagnosed with UTUC who underwent RNU at the Affiliated Hospital of Qingdao University between January 2020 and June 2024. This study was approved by the institutional ethics committee (Approval No. QYFYEC2023-68). All participants provided written informed consent in accordance with the Declaration of Helsinki. A total of 320 patients were initially screened. Forty-four patients were excluded due to concomitant malignant tumors (n = 9), a history of major abdominal surgery (n = 14), or missing clinical data (n = 21). The final cohort comprised 276 patients (Fig.1). Patient Population Among these patients, 131 (47.46%) underwent SRLRNU, while 145 (52.54%) underwent TRLRNU. Risk stratification was performed based on the 2023 updated guidelines of the European Association of Urology (EAU). All patients who were suspected of having UTUC underwent urinary cytology testing. For those with negative cytological results but radiological suspicion of UTUC, diagnostic ureteroscopy (URS) was performed to obtain biopsy samples. Prior to surgery, all patients underwent comprehensive preoperative assessments, including contrast-enhanced computed tomography (CT) urography, chest CT, and abdominal ultrasound to identify any nodules or distant metastases. In cases where CT findings were inconclusive, magnetic resonance imaging (MRI) or 18F-FDG-PET/CT was employed for further evaluation. Inclusion criteria included age 18–85 years, American Society of Anesthesiologists (ASA) class I–IV, imaging or pathological diagnosis of UTUC, adequate function of vital organs and available complete clinical, pathological, and follow-up data. Exclusion criteria involved history of other active malignancies or concurrent malignant tumors at the time of diagnosis, severe cardiovascular or neurological diseases, pregnancy, prior major abdominal surgery, body mass index (BMI) over 40 kg/m², active infections, concurrent bladder disease, pregnancy or lactation, uncontrolled epilepsy or psychiatric disorders, and a history of stroke or intracerebral hemorrhage within the previous six months. Patients with missing critical data or poor compliance were excluded. Surgical Techniques Both SRLRNU and TRLRNU were performed laparoscopically through the retroperitoneal approach. SRLRNU utilized a single modified oblique lithotomy position throughout the operation, avoiding intraoperative repositioning. The patient was placed in a 75° oblique supine position, with two back supports fixed at the shoulder and hip regions. As shown in Fig.2A and 2B, during nephrectomy, port B served as the observation port, while ports A and C were used as operating ports. When managing the distal ureter, port D was used for observation, ports A and C remained as the main operating ports, and ports B and E served as auxiliary operating ports. At the end of the procedure, the specimen was extracted through the incision between ports C and D. The specific surgical steps include: 1 Nephrectomy with proximal ureteral mobilization.2 Mobilization of the ureter above the iliac vessels. 3 Expansion of the retroperitoneal pelvic space. 4 Mobilization of the ureter below the iliac vessels. 5 Mobilization of the ureter between the iliac vessels and the umbilical artery. 6 Transection of the umbilical artery. 7 Mobilization of the ureter below the umbilical artery. 8 Intramural ureter and bladder cuff excision (Fig.2C, 2D). 9 Bladder wall suturing. 10 Extracting the surgical specimen. A detailed animated representation of the full procedure is provided in Supplementary video. In contrast, patients in the TRLRNU group were repositioned to the lithotomy position after nephrectomy to facilitate distal ureter and bladder cuff excision. The bladder cuff was excised via a small open incision depending on surgeon preference [11,12]. All surgeries were conducted by trained urologists following standardized procedures. Follow-Up and Outcomes Postoperative follow-up was scheduled every three months during the first two years and included cystoscopy, urinary cytology, physical examination, vital signs assessment, routine blood and urine tests, and adverse event questionnaires. CT urography (CTU) was performed every six months. After two years, patients in the low-risk group underwent annual CTU, while high-risk patients continued biannual CTU, per the 2023 EAU guidelines. One month after surgery, a single intravesical instillation of pirarubicin (30 mg) was administered. The primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), cancer-specific survival (CSS), recurrence-free survival (RFS), and perioperative outcomes. Recurrence was defined as local (e.g., intravesical or distant) tumor relapse, and progression referred to nodal or distant metastases. Treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs) were monitored during hospitalization and follow-up, and were evaluated using the Clavien-Dindo classification system[13]. Statistical Analysis The statistical analysis was conducted utilizing R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria) along with GraphPad Prism (GraphPad Software, San Diego, CA, USA). Continuous variable results were summarized either as means (with standard deviations) or medians (along with interquartile ranges), based on the normality of the data evaluated through the Shapiro-Wilk test. To compare baseline characteristics of continuous variables, either the independent samples t-test or Mann-Whitney U test was employed, depending on the normal distribution of the data. Categorical variables were analyzed using Pearson chi-square test, Yates’ corrected chi-square test, or Fisher's exact test, contingent upon the frequency of the data. Kaplan-Meier analysis was utilized to estimate survival rates, while the log-rank test assessed differences between patient groups. The Cox proportional hazards regression model was employed to calculate hazard ratios (HR) and 95% confidence intervals (95% CIs) as well as for both uni- and multivariate survival analyses. All statistical tests were two-sided, with a significance threshold set at P < 0.05. Result A total of 276 UTUC patients were included, with 131 undergoing SRLRNU and 145 undergoing TRLRNU. Detailed demographic and clinical data are presented in Table 1. There were no statistically significant differences in age (68.52 ± 11.73 vs. 68.44 ± 8.93, P > 0.05) or gender distribution between groups. However, the follow-up duration was significantly shorter in the SRLRNU group (23.34 ± 13.90 vs. 29.31 ± 15.82 months, P < 0.001), which likely reflects the fact that, during the early implementation phase of SRLRNU, most patients and surgeons preferred the more established TRLRNU approach. Comorbidities were generally comparable, except for a higher prevalence of cardiovascular disease in the TRLRNU group (29.66% vs. 17.56%, P = 0.019). No significant difference was observed in ASA class distribution. As shown in Table 2, the SRLRNU group had a significantly shorter operative time (124.47 ± 42.54 vs. 152.13 ± 44.22min vs. 152.13 ± 44.22 min, p < 0.001), less estimated blood loss (47.61 ± 140.75 vs. 71.45 ± 108.42 ml, p < 0.001), shorter hospital stay (P = 0.023), and reduced hospitalization cost (P < 0.001). The incidence of postoperative hypoproteinemia was lower in the SRLRNU group (77.24% vs. 60.31%, P = 0.002). These potential advantages may be attributed to earlier postoperative gastrointestinal recovery and mobilization in patients undergoing SRLRNU. No significant differences were observed in postoperative Clavien-Dindo grades between the groups, with most complications being grade ≤1. Oncologically, the TRLRNU group had a higher proportion of high-grade tumors (84.83% vs. 72.52%, P = 0.012) and more ureteral tumors (60.69% vs. 35.88%, P < 0.001), whereas SRLRNU patients more often had renal pelvic tumors (64.12%). This finding may suggest that surgeons tend to choose the transperitoneal approach, which offers a larger operative field, when facing potentially complex intraoperative scenarios. Kaplan–Meier analyses (Fig.3) showed no statistically significant differences between SRLRNU and TRLRNU in 4-year OS (P = 0.307), CSS (P = 0.140), PFS (P = 0.117), or RFS (P = 0.713). Due to insufficient long-term follow-up for SRLRNU patients, we further compared 3-year oncologic outcomes. The SRLRNU group showed higher rates than the TRLRNU group in OS (75.68% vs. 68.14%), CSS (91.37% vs. 82.61%), PFS (90.92% vs. 80.62%), and RFS (73.26% vs. 70.91%), though none of these differences reached statistical significance (P > 0.05). Subgroup analyses (Fig.S1) by T stage also revealed no significant differences in survival outcomes. However, trends in CSS and PFS (HRs of 1.87 and 1.94, respectively) suggest potential clinical advantage favoring SRLRNU, pending longer follow-up. Of note, in the T2 subgroup (Fig.S1B), the CSS and PFS of TRLRNU patients could not be statistically evaluated due to the absence of observed deaths, thereby limiting interpretability. Univariate and multivariate Cox regression analyses were performed according to EAU guidelines (Table S1), which identified tumor T stage, age, and ASA score as independent predictors of OS in the SRLRNU group (P < 0.05), while ASA and Clavien-Dindo grade were significant in the TRLRNU group (P 0.05). However, a potential trend favoring SRLRNU was observed in patients with ureteral tumors, suggesting it may offer improved survival in this subgroup. Discussion This study is the first to compare long-term oncological and perioperative outcomes between SRLRNU and TRLRNU in UTUC patients. Although no statistically significant differences were observed in OS, CSS, PFS, or RFS between the two groups, SRLRNU showed a trend toward better cancer-specific and progression-free survival. This may be partially explained by the lower tumor grade and renal pelvic tumor predominance in the SRLRNU group, as well as reduced surgical trauma and faster recovery. Notably, SRLRNU significantly reduced operative time, intraoperative blood loss, hospitalization duration, and total medical cost. These advantages are largely attributed to the elimination of intraoperative repositioning, streamlined trocar placement, and minimized bowel interference. Additionally, a lower incidence of postoperative hypoproteinemia was observed in SRLRNU patients, likely reflecting faster gastrointestinal recovery. UTUC surgery can be performed via two distinct routes. The transperitoneal approach provides a larger operative field that is beneficial for managing larger tumors or those that have invaded adjacent intra-abdominal structures, making it the preferred option in such scenarios[14]. In contrast, the retroperitoneal route offers clearer anatomical landmarks and avoids interference from the intestines, making it especially advantageous for kidney-sparing surgeries in UTUC[15]. By forgoing patient repositioning during the procedure, our center primarily employs the retroperitoneal method. The use of SRLRNU not only achieves effective tumor control but also significantly enhances perioperative outcomes, thereby offering a superior therapeutic alternative for UTUC patients. Furthermore, by reducing the need for intraoperative positional adjustments and shortening the overall operating time, SRLRNU supports the advancement of minimally invasive surgical techniques and underscores its value in clinical. The SRLRNU method is characterized by shorter operative time, less blood loss, and quicker postoperative recovery. Although similar findings have been reported by others using robot-assisted surgery[16], our data obtained from conventional laparoscopic procedures show that experienced laparoscopic surgeons can complete the procedure in a median time of 115 minutes compared to approximately three hours with robotic assistance. This suggests that while robotic systems may facilitate certain technical aspects such as bladder cuff suturing, proficient laparoscopic techniques can also achieve rapid surgical completion. The results indicate that SRLRNU may be best suited for patients with lower tumor burden or tumors in more accessible locations. By clearly delineating the suitable patient populations for each surgical technique, this study provides valuable guidance for individualized treatment planning. In clinical, urologists frequently opt for the transperitoneal approach for advanced UTUC, especially when imaging shows invasion into surrounding tissues, because the transperitoneal route not only offers a larger operative field for managing complex cases but also is essential when resection of part of the peritoneum becomes necessary[17]. Although patients with locally advanced tumors (T3/T4 or N+) generally have poorer prognoses, it is widely believed that RNU combined with lymphadenectomy can confer a survival benefit[18,19]. However, some studies suggest that systemic treatments such as chemotherapy or immunotherapy may yield better OS outcomes for patients with distant metastases[20]. Unfortunately, there is currently insufficient evidence to determine whether the combination of drug therapy and debulking surgery translates into improved OS. Similarly, while ipsilateral lymphadenectomy may improve survival in locally advanced tumors, its primary role is often to accurately stage the disease and guide adjuvant therapy[21]. There remains a lack of robust prospective, randomized controlled trials to determine both the necessity and the extent of lymph node dissection. Kidney-Sparing Surgery (KSS) represents another focus in current UTUC research. For tumors confined to the ureter, options include ureteroureterostomy, distal ureterectomy with reimplantation, and laser ablation[1]. These approaches demand meticulous patient selection and shared decision-making due to uncertainties regarding recurrence[22]. With advancements in surgical instruments and accumulating experience, these procedures can now be performed via laparoscopy or robot-assisted surgery, significantly reducing surgical trauma and enhancing patient acceptance[23]. In our center, laparoscopic ureteroureterostomy is typically performed for ureteral tumors smaller than 2 cm, whereas distal ureterectomy with bladder cuff reimplantation is reserved for tumors located at the distal ureter. Our experience indicates that a spiral-shaped bladder flap generally meets the needs of most reimplantation procedures. For patients with multiple ureteral tumors or those requiring long-segment ureterectomy, we employ one of three approaches: on the right side, an appendiceal substitution is preferred; another option is ileal substitution, usually performed via the transperitoneal route with robotic assistance recommended due to multiple anastomoses; and lastly, a tongue mucosa substitute technique is used, where the thickness of the harvested mucosa is critical for success. For low-risk UTUC patients, endoscopic management is also an alternative solution[1]. Procedures involving ureteroscopy, flexible ureteroscopy, or percutaneous nephroscopy, combined with laser or cryoablation, can be employed for tumor excision[24]. These methods remain under investigation and require strict adherence to surgical indications, as well as rigorous postoperative surveillance, due to concerns over incomplete resection and potential tumor seeding. Some studies have reported that for low-risk UTUC, endoscopic treatment yields satisfactory OS and RFS[25,26]. Thus, for patients with a high desire to preserve renal function or those with a solitary kidney, ablation techniques are a viable option, provided that patients can commit to stringent follow-up. However, when using a percutaneous approach, there is a risk of tumor fragments descending via irrigation flow into the ureter or bladder[27]. Some researchers have noted recurrence rates of 52% with ureteroscopy for low-grade disease compared to 23% with a percutaneous approach[28]. Despite the direct access provided by a percutaneous tract and the use of larger, more comprehensive instruments, making it more suitable for renal pelvic UTUC resection, the higher rate of severe complications must be considered. In one instance of percutaneous laser resection for UTUC in a patient with an ileal conduit following radical cystectomy, we observed that small tumor fragments were washed down the ureter, raising concerns about subsequent seeding. These factors underscore the necessity of strict adherence to surgical indications, collaborative treatment planning with patients, and rigorous long-term follow-up when choosing this approach. Nonetheless, this study has limitations. As a single-center retrospective study with a relatively homogeneous sample, our findings may be subject to selection bias and may not be generalizable. Although the study was conducted under strict quality control, multi-center data would likely offer a more comprehensive comparison of the efficacy of SRLRNU versus TRLRNU. Moreover, despite a collection period of approximately five years, the mean follow-up of 26 months is insufficient to fully assess the long-term survival outcomes of UTUC patients, particularly regarding five-year recurrence and survival rates. The statistically significant differences in cardiovascular comorbidities and tumor locations between the two groups, despite adjustment for these confounders in multivariate analysis, could still potentially influence the interpretation of our results. We advocate for future prospective, randomized controlled trials with larger sample sizes and multi-center participation to validate our conclusions, as well as more in-depth studies based on tumor stage, location, and patient characteristics to provide more precise individualized treatment guidance. Conclusion SRLRNU offers a safe and efficient alternative to TRLRNU for appropriately selected UTUC patients, particularly those with localized or surgically favorable tumors. It preserves oncological efficacy while enhancing perioperative recovery and reducing healthcare costs. This study provides valuable clinical evidence supporting SRLRNU as a viable treatment strategy in the evolving landscape of minimally invasive urologic oncology. Abbreviation ASA American Society of Anesthesiologists BMI Body Mass Index CD Clavien-Dindo Classification CI Confidence Interval CSS Cancer-Specific Survival CT Computed Tomography CTU Computed Tomography Urography EAU European Association of Urology eGFR Estimated Glomerular Filtration Rate HR Hazard Ratio KSS Kidney-Sparing Surgery MRI Magnetic Resonance Imaging OS Overall Survival PET/CT Positron Emission Tomography / Computed Tomography PFS Progression-Free Survival RFS Recurrence-Free Survival RNU Radical Nephroureterectomy SAE Serious Adverse Event SRLRNU Single-position Retroperitoneal Laparoscopic Radical Nephroureterectomy TEAE Treatment-Emergent Adverse Event TRLRNU Traditional Retroperitoneal Laparoscopic Radical Nephroureterectomy URS Ureteroscopy UTUC Upper Tract Urothelial Carcinoma Declarations Ethics approval and consent to participate Ethical approval: The study protocol was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University (Approval No. QYFYEC2023-68). Informed consent: All participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare no conflicts of interest. Funding This research was supported by a grant of the National Natural Science Foundation of China (No.82200759) and supported by the Qingdao Science and Technology Benefit Demonstration Project (No: 24-1-8-smjk-4-nsh) Authors' contributions Kai Zhao: Conceptualization, Methodology, Writing – original draft. Jiao Huang: Data curation, Resources, Investigation, Writing – review & editing. Yuxuan He: Software, Formal analysis, Data curation, Visualization. Bin Dong: Data collection, Investigation, Resources. Rui Zhang: Data collection, Investigation, Data validation. Zongliang Zhang: Methodology, Data collection. Xinbao Yin: Visualization, Writing – review & editing. Xiaokun Yang: Formal analysis, Resources. Guoyi Jiang: Methodology. Woong Jin Bae: Methodology, Writing – review & editing. Ke Wang: Supervision, Validation, Writing – review & editing. Guanqun Zhu: Conceptualization, Project administration, Funding acquisition, Supervision, Writing – review & editing. Acknowledgements Not applicable. References Roupret, M., Seisen, T., Birtle, A. J., Capoun, O., Comperat, E. M., Dominguez-Escrig, J. L., Gurses Andersson, I., Liedberg, F., Mariappan, P., Hugh Mostafid, A., Pradere, B., van Rhijn, B. W. G., Shariat, S. F., Rai, B. P., Soria, F., Soukup, V., Wood, R. G., Xylinas, E. N., Masson-Lecomte, A., & Gontero, P. (2023). European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update. Eur Urol , 84 (1), 49-64. https://doi.org/10.1016/j.eururo.2023.03.013 Coleman, J. A., Clark, P. E., Bixler, B. R., Buckley, D. I., Chang, S. 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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 , 5 (2), 205-223. https://doi.org/10.1016/j.euf.2017.10.003 Ditonno, F., Franco, A., Wu, Z., Wang, L., Abdollah, F., Simone, G., Correa, A. F., Ferro, M., Perdona, S., Amparore, D., Bhanvadia, R., Bronimann, S., Puri, D., Mendiola, D. F., Ben-David, R., Moon, S. C., Yong, C., Moghaddam, F. S., Ghoreifi, A.,…Autorino, R. (2024). Robot-assisted nephroureterectomy: surgical and mid-term oncological outcomes in over 1100 patients (ROBUUST 2.0 collaborative group). BJU Int , 134 (6), 967-975. https://doi.org/10.1111/bju.16526 Stewart, G. D., Humphries, K. J., Cutress, M. L., Riddick, A. C., McNeill, S. A., & Tolley, D. A. (2011). 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Neoadjuvant and Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A 2020 Systematic Review and Meta-analysis, and Future Perspectives on Systemic Therapy. Eur Urol , 79 (5), 635-654. https://doi.org/10.1016/j.eururo.2020.07.003 Dominguez-Escrig, J. L., Peyronnet, B., Seisen, T., Bruins, H. M., Yuan, C. Y., Babjuk, M., Bohle, A., Burger, M., Comperat, E. M., Gontero, P., Lam, T., MacLennan, S., Mostafid, H., Palou, J., van Rhijn, B. W. G., Sylvester, R. J., Zigeuner, R., Shariat, S. F., & Roupret, M. (2019). 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 , 5 (2), 224-241. https://doi.org/10.1016/j.euf.2017.09.015 Zhou, L., Huang, C., Sun, S., Ning, K., & Tang, S. (2025). Kidney sparing surgery versus radical nephroureterectomy in upper tract urothelial carcinoma: a meta-analysis and systematic review. Front Oncol , 15 , 1448079. https://doi.org/10.3389/fonc.2025.1448079 Seisen, T., Peyronnet, B., Dominguez-Escrig, J. L., Bruins, H. M., Yuan, C. Y., Babjuk, M., Bohle, A., Burger, M., Comperat, E. M., Cowan, N. C., Kaasinen, E., Palou, J., van Rhijn, B. W., Sylvester, R. J., Zigeuner, R., Shariat, S. F., & Roupret, M. (2016). 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 , 70 (6), 1052-1068. https://doi.org/10.1016/j.eururo.2016.07.014 Shvero, A., Abu-Ghanem, Y., Laufer, M., Dotan, Z. A., Zilberman, D. E., Mor, Y., Portnoy, O., Fridmen, E., Winkler, H., & Kleinmann, N. (2021). Endoscopic Treatment for Large Multifocal Upper Tract Urothelial Carcinoma. J Urol , 205 (4), 1039-1046. https://doi.org/10.1097/JU.0000000000001505 Laukhtina, E., Kawada, T., Quhal, F., Yanagisawa, T., Rajwa, P., von Deimling, M., Pallauf, M., Bianchi, A., Majdoub, M., Enikeev, D., Fajkovic, H., Teoh, J. Y., Roupret, M., Gontero, P., & Shariat, S. F. (2023). Oncologic and Safety Outcomes for Retrograde and Antegrade Endoscopic Surgeries for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis. Eur Urol Focus , 9 (2), 258-263. https://doi.org/10.1016/j.euf.2022.11.014 Chen, Y., Xu, C., Mou, Z., Hu, Y., Yang, C., Hu, J., Chen, X., Luo, J., Zou, L., & Jiang, H. (2024). Endoscopic Cryoablation Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. Eur Urol Oncol , 7 (6), 1453-1461. https://doi.org/10.1016/j.euo.2024.04.012 Palou, J., Piovesan, L. F., Huguet, J., Salvador, J., Vicente, J., & Villavicencio, H. (2004). Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup. J Urol , 172 (1), 66-69. https://doi.org/10.1097/01.ju.0000132128.79974.db Cutress, M. L., Stewart, G. D., Zakikhani, P., Phipps, S., Thomas, B. G., & Tolley, D. A. (2012). Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int , 110 (5), 614-628. https://doi.org/10.1111/j.1464-410X.2012.11068.x Tables Tables 1 to 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterials.docx Supplementaryvideo.mp4 Tables.docx Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2026 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 19 Jan, 2026 Reviews received at journal 18 Jan, 2026 Reviews received at journal 15 Jan, 2026 Reviews received at journal 14 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviews received at journal 13 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviewers invited by journal 13 Jan, 2026 Editor invited by journal 09 Jan, 2026 Editor assigned by journal 16 Dec, 2025 Submission checks completed at journal 16 Dec, 2025 First submitted to journal 16 Dec, 2025 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. 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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-8217690","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":575025325,"identity":"58d586aa-4e95-430d-a4a8-16cda95e7242","order_by":0,"name":"Kai Zhao","email":"","orcid":"","institution":"the Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Zhao","suffix":""},{"id":575025329,"identity":"92ac4f38-4169-4c8b-bdef-e95ee7289551","order_by":1,"name":"Jiao Huang","email":"","orcid":"","institution":"Huangdao District Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiao","middleName":"","lastName":"Huang","suffix":""},{"id":575025331,"identity":"53947340-b895-4505-98c7-938b8f4cb850","order_by":2,"name":"Yuxuan He","email":"","orcid":"","institution":"the Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Yuxuan","middleName":"","lastName":"He","suffix":""},{"id":575025333,"identity":"a03fb0e8-3ad4-4747-88bb-944ff1be7c75","order_by":3,"name":"Bin Dong","email":"","orcid":"","institution":"the Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Dong","suffix":""},{"id":575025334,"identity":"9a480e71-5b2f-404a-9c63-73f5a197f562","order_by":4,"name":"Rui Zhang","email":"","orcid":"","institution":"the Affiliated Hospital of Qingdao 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University","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Wang","suffix":""},{"id":575025344,"identity":"3cd2c2a0-facc-46e0-b594-f9b575f9601e","order_by":11,"name":"Guanqun Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYDACZiT2gQ8GNnYkaWE8OKMgLZk0Cw/zfDjE2EBImcFx5ocPv7bZ5fHdyD1w2MbgADMD++GjG/BpkWxmMzaWbUsulryRl3A4x+AOHwNPWtoNfFr4mRnMpCXbmBM33MgxAGp5xswgwWOGVwsbM/s3oJZ6iBYLg8OMDYS08DPzmEl+bDsM0cJAjBbJZp5iY4ZzxxNnnnljcLDHIC2ZjZBfDM4f3/jwR1l1Yt/xHOMPP/7Y2PGzHz6GVwsIMPOAyAMw3xFSDgKMP5C1jIJRMApGwShABwAhmk0RDYEe1wAAAABJRU5ErkJggg==","orcid":"","institution":"the Affiliated Hospital of Qingdao University","correspondingAuthor":true,"prefix":"","firstName":"Guanqun","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2025-11-27 04:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8217690/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8217690/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-026-02075-8","type":"published","date":"2026-02-13T15:57:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":100560979,"identity":"895ba78a-9246-42c5-bb61-2cd0756333eb","added_by":"auto","created_at":"2026-01-19 08:43:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80591,"visible":true,"origin":"","legend":"\u003cp\u003eA schematic overview of the study framework, illustrating the patient recruitment process, application of inclusion criteria, and final selection of individuals diagnosed with upper tract urothelial carcinoma for analysis.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/d3c9a655ddd96d7055783b3d.jpg"},{"id":100561246,"identity":"20b51dd0-c915-4e24-9ee0-2d8cba49730a","added_by":"auto","created_at":"2026-01-19 08:43:58","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":120836,"visible":true,"origin":"","legend":"\u003cp\u003ePort Placement, Patient Positioning, and Key Steps during SRLRNU. (A) Anterior schematic view of trocar placement. (B) Intraoperative photograph after surgery showing the patient in a 75° modified oblique lateral decubitus position, with the relative locations of trocars marked. During nephrectomy, port B served as the observation port, while ports A and C were used as operating ports. When managing the distal ureter, port D was used for observation, ports A and C remained as the main operating ports, and ports B and E served as auxiliary operating ports. F is umbilicus. (C) Intraoperative illustration showing the dissection of the intramural ureter from the bladder wall using retroperitoneal instruments. (D) Completion of intramural ureter and bladder cuff excision with adequate mobilization and transection under laparoscopic vision.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/c0dbd1d88e9a64543cc9454d.jpg"},{"id":100561316,"identity":"5bfe4a07-f874-4ed5-9493-6d34957824f7","added_by":"auto","created_at":"2026-01-19 08:43:59","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":93030,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves for overall survival, cancer-specific survival, progression-free survival, and recurrence-free survival in the SRLRNU and TRLRNU groups. SRLRNU = single-position retroperitoneal laparoscopic radical nephroureterectomy. TRLRNU = typically retroperitoneal laparoscopic radical nephroureterectomy. HR = hazard ratio. The values in parentheses represent the 95% confidence intervals. P \u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/95915da3438ac82e204f2411.jpg"},{"id":100561204,"identity":"ec7ea372-d9db-4b38-b7e8-e35deeb09cae","added_by":"auto","created_at":"2026-01-19 08:43:58","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":88685,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis examining tumor-related variables on OS. SRLRNU = single-position retroperitoneal laparoscopic radical nephroureterectomy. TRLRNU = typically retroperitoneal laparoscopic radical nephroureterectomy. HR = hazard ratio. 95%CI = 95% confidence intervals. P \u0026lt; 0.05 indicates statistical significance.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/ed3e4343fe88c9498cea89c0.jpg"},{"id":102785761,"identity":"04423c95-2863-4eb9-ad8e-d75bd454f3eb","added_by":"auto","created_at":"2026-02-16 16:09:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":966236,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/c357d5d8-369c-41c3-9fdd-d187dc965634.pdf"},{"id":100561025,"identity":"38d63f4a-a33c-4ab4-88cf-750309e032bf","added_by":"auto","created_at":"2026-01-19 08:43:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":233927,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/1bf6a07f54a945e9620a60a2.docx"},{"id":100561460,"identity":"fe17ffa0-2c51-4f2c-a79d-045e90a5c0e7","added_by":"auto","created_at":"2026-01-19 08:44:04","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":609908453,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryvideo.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/57a68a79c7e4a943e7d424ac.mp4"},{"id":100561080,"identity":"832a74d9-f311-4de4-88ec-e5c42266dc47","added_by":"auto","created_at":"2026-01-19 08:43:56","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":28676,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8217690/v1/52edf3262e99e2e53cd77c36.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Position Versus Traditional Retroperitoneal Laparoscopic Nephroureterectomy for UTUC: Long-Term Survival and Perioperative Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUpper tract urothelial carcinoma (UTUC) is a relatively rare malignancy, accounting for 5\u0026ndash;10% of all urothelial cancers, but its incidence has been increasing in recent years, particularly in East Asia [1]. Radical nephroureterectomy (RNU) with bladder cuff excision remains the gold standard for managing high-risk UTUC according to international guidelines [2].\u003c/p\u003e\n\u003cp\u003eLaparoscopic approaches to RNU have gained popularity due to reduced morbidity and faster recovery compared to open surgery [3,4,5]. Among them, the retroperitoneal laparoscopic technique is favored for its direct access to the kidney and ureter, avoidance of bowel interference, and potential reduction in postoperative complications [6,7]. However, the traditional retroperitoneal approach (TRLRNU) typically requires intraoperative repositioning, from lateral decubitus to lithotomy, to facilitate bladder cuff excision, which increases operative time, complexity, and infection risk [8,9].\u003c/p\u003e\n\u003cp\u003eTo overcome these limitations, a single-position retroperitoneal laparoscopic radical nephroureterectomy (SRLRNU) technique has been introduced. By maintaining the patient in a single lateral decubitus position throughout the procedure, SRLRNU aims to streamline surgical workflow and potentially improve perioperative outcomes. Despite its increasing adoption in clinical practice, evidence comparing the safety, feasibility, and oncologic equivalence of SRLRNU and TRLRNU remains limited [10].\u003c/p\u003e\n\u003cp\u003eIn this study, detailed surgical steps and port configurations of SRLRNU were optimized and presented. We sought to compare the perioperative and oncologic outcomes of SRLRNU and TRLRNU in patients with UTUC. We aimed to determine whether SRLRNU could offer improved intraoperative efficiency without compromising long-term survival, thereby supporting its broader application in routine urologic oncology practice.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study included 276 patients diagnosed with UTUC who underwent RNU at the Affiliated Hospital of Qingdao University between January 2020 and June 2024. This study was approved by the institutional ethics committee (Approval No. QYFYEC2023-68). All participants provided written informed consent in accordance with the Declaration of Helsinki. A total of 320 patients were initially screened. Forty-four patients were excluded due to concomitant malignant tumors (n = 9), a history of major abdominal surgery (n = 14), or missing clinical data (n = 21). The final cohort comprised 276 patients (Fig.1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong these patients, 131 (47.46%) underwent SRLRNU, while 145 (52.54%) underwent TRLRNU. Risk stratification was performed based on the 2023 updated guidelines of the European Association of Urology (EAU). All patients who were suspected of having UTUC underwent urinary cytology testing. For those with negative cytological results but radiological suspicion of UTUC, diagnostic ureteroscopy (URS) was performed to obtain biopsy samples. Prior to surgery, all patients underwent comprehensive preoperative assessments, including contrast-enhanced computed tomography (CT) urography, chest CT, and abdominal ultrasound to identify any nodules or distant metastases. In cases where CT findings were inconclusive, magnetic resonance imaging (MRI) or 18F-FDG-PET/CT was employed for further evaluation.\u003c/p\u003e\n\u003cp\u003eInclusion criteria included age 18\u0026ndash;85 years, American Society of Anesthesiologists (ASA) class I\u0026ndash;IV, imaging or pathological diagnosis of UTUC, adequate function of vital organs and available complete clinical, pathological, and follow-up data. Exclusion criteria involved history of other active malignancies or concurrent malignant tumors at the time of diagnosis, severe cardiovascular or neurological diseases, pregnancy, prior major abdominal surgery, body mass index (BMI) over 40 kg/m\u0026sup2;, active infections, concurrent bladder disease, pregnancy or lactation, uncontrolled epilepsy or psychiatric disorders, and a history of stroke or intracerebral hemorrhage within the previous six months. Patients with missing critical data or poor compliance were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth SRLRNU and TRLRNU were performed laparoscopically through the retroperitoneal approach. SRLRNU utilized a single modified oblique lithotomy position throughout the operation, avoiding intraoperative repositioning. The patient was placed in a 75\u0026deg; oblique supine position, with two back supports fixed at the shoulder and hip regions. As shown in Fig.2A and 2B, during nephrectomy, port B served as the observation port, while ports A and C were used as operating ports. When managing the distal ureter, port D was used for observation, ports A and C remained as the main operating ports, and ports B and E served as auxiliary operating ports. At the end of the procedure, the specimen was extracted through the incision between ports C and D. The specific surgical steps include: 1 Nephrectomy with proximal ureteral mobilization.2 Mobilization of the ureter above the iliac vessels. 3 Expansion of the retroperitoneal pelvic space. 4 Mobilization of the ureter below the iliac vessels. 5 Mobilization of the ureter between the iliac vessels and the umbilical artery. 6 Transection of the umbilical artery. 7 Mobilization of the ureter below the umbilical artery. 8 Intramural ureter and bladder cuff excision (Fig.2C, 2D). 9 Bladder wall suturing. 10 Extracting the surgical specimen. A detailed animated representation of the full procedure is provided in Supplementary video. In contrast, patients in the TRLRNU group were repositioned to the lithotomy position after nephrectomy to facilitate distal ureter and bladder cuff excision. The bladder cuff was excised via a small open incision depending on surgeon preference [11,12]. All surgeries were conducted by trained urologists following standardized procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-Up and Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative follow-up was scheduled every three months during the first two years and included cystoscopy, urinary cytology, physical examination, vital signs assessment, routine blood and urine tests, and adverse event questionnaires. CT urography (CTU) was performed every six months. After two years, patients in the low-risk group underwent annual CTU, while high-risk patients continued biannual CTU, per the 2023 EAU guidelines. One month after surgery, a single intravesical instillation of pirarubicin (30 mg) was administered.\u003c/p\u003e\n\u003cp\u003eThe primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), cancer-specific survival (CSS), recurrence-free survival (RFS), and perioperative outcomes. Recurrence was defined as local (e.g., intravesical or distant) tumor relapse, and progression referred to nodal or distant metastases. Treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs) were monitored during hospitalization and follow-up, and were evaluated using the Clavien-Dindo classification system[13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analysis was conducted utilizing R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria) along with GraphPad Prism (GraphPad Software, San Diego, CA, USA). Continuous variable results were summarized either as means (with standard deviations) or medians (along with interquartile ranges), based on the normality of the data evaluated through the Shapiro-Wilk test. To compare baseline characteristics of continuous variables, either the independent samples t-test or Mann-Whitney U test was employed, depending on the normal distribution of the data. Categorical variables were analyzed using Pearson chi-square test, Yates\u0026rsquo; corrected chi-square test, or Fisher\u0026apos;s exact test, contingent upon the frequency of the data. Kaplan-Meier analysis was utilized to estimate survival rates, while the log-rank test assessed differences between patient groups. The Cox proportional hazards regression model was employed to calculate hazard ratios (HR) and 95% confidence intervals (95% CIs) as well as for both uni- and multivariate survival analyses. All statistical tests were two-sided, with a significance threshold set at P \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 276 UTUC patients were included, with 131 undergoing SRLRNU and 145 undergoing TRLRNU.\u0026nbsp;Detailed demographic and clinical data are presented in Table 1.\u0026nbsp;There were no statistically significant differences in age (68.52 \u0026plusmn; 11.73 vs. 68.44 \u0026plusmn; 8.93, P \u0026gt; 0.05) or gender distribution between groups. However, the follow-up duration was significantly shorter in the SRLRNU group (23.34 \u0026plusmn; 13.90 vs. 29.31 \u0026plusmn; 15.82 months, P \u0026lt; 0.001), which\u0026nbsp;likely reflects the fact that, during the early implementation phase of SRLRNU, most patients and surgeons preferred the more established TRLRNU approach.\u0026nbsp;Comorbidities were generally comparable, except for a higher prevalence of cardiovascular disease in the TRLRNU group (29.66% vs. 17.56%, P = 0.019). No significant difference was observed in ASA class distribution.\u003c/p\u003e\n\u003cp\u003eAs shown in Table 2, the SRLRNU group had a significantly shorter operative time (124.47 \u0026plusmn; 42.54 vs. 152.13 \u0026plusmn; 44.22min vs. 152.13 \u0026plusmn; 44.22 min, p \u0026lt; 0.001), less estimated blood loss (47.61 \u0026plusmn; 140.75 vs. 71.45 \u0026plusmn; 108.42 ml, p \u0026lt; 0.001), shorter hospital stay (P = 0.023), and reduced hospitalization cost (P \u0026lt; 0.001). The incidence\u0026nbsp;of postoperative hypoproteinemia was lower in the SRLRNU group (77.24% vs. 60.31%, P = 0.002).\u0026nbsp;These\u0026nbsp;potential advantages may be attributed to earlier postoperative gastrointestinal recovery and mobilization in patients undergoing SRLRNU.\u0026nbsp;No significant differences were observed in postoperative Clavien-Dindo grades between the groups, with most complications being grade \u0026le;1. Oncologically, the TRLRNU group had a higher proportion of high-grade tumors (84.83% vs. 72.52%, P = 0.012) and more ureteral tumors (60.69% vs. 35.88%, P \u0026lt; 0.001), whereas SRLRNU patients more often had renal pelvic tumors (64.12%).\u0026nbsp;This finding may suggest that surgeons tend to choose the transperitoneal approach, which offers a larger operative field, when facing potentially complex intraoperative scenarios.\u003c/p\u003e\n\u003cp\u003eKaplan\u0026ndash;Meier analyses (Fig.3) showed no statistically significant differences between SRLRNU and TRLRNU in 4-year OS (P = 0.307), CSS (P = 0.140), PFS (P = 0.117), or RFS (P = 0.713).\u0026nbsp;Due to insufficient long-term follow-up for SRLRNU patients, we further compared 3-year oncologic outcomes. The SRLRNU group showed higher rates than the TRLRNU group in OS (75.68% vs. 68.14%), CSS (91.37% vs. 82.61%), PFS (90.92% vs. 80.62%), and RFS (73.26% vs. 70.91%), though none of these differences reached statistical significance (P \u0026gt; 0.05).\u0026nbsp;Subgroup analyses (Fig.S1) by T stage also revealed no significant differences in survival outcomes. However, trends in CSS and PFS (HRs of 1.87 and 1.94, respectively) suggest potential clinical advantage favoring SRLRNU, pending longer follow-up.\u0026nbsp;Of note, in the T2 subgroup (Fig.S1B), the CSS and\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePFS of TRLRNU patients could not be statistically evaluated due to the absence of observed deaths, thereby limiting interpretability.\u003c/p\u003e\n\u003cp\u003eUnivariate and multivariate Cox regression analyses were performed according to EAU guidelines (Table S1), which identified tumor T stage, age, and ASA score as independent predictors of OS in the SRLRNU group (P \u0026lt; 0.05), while ASA and Clavien-Dindo grade were significant in the TRLRNU group (P \u0026lt; 0.05). Further Subgroup analyses by T stage for OS, CSS, PFS, and RFS in Fig.4 showed no significant differences between the two surgical techniques (P \u0026gt; 0.05). However, a potential trend favoring SRLRNU was observed in patients with ureteral tumors, suggesting it may offer improved survival in this subgroup.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to compare long-term oncological and perioperative outcomes between SRLRNU and TRLRNU in UTUC patients. Although no statistically significant differences were observed in OS, CSS, PFS, or RFS between the two groups, SRLRNU showed a trend toward better cancer-specific and progression-free survival. This may be partially explained by the lower tumor grade and renal pelvic tumor predominance in the SRLRNU group, as well as reduced surgical trauma and faster recovery. Notably, SRLRNU significantly reduced operative time, intraoperative blood loss, hospitalization duration, and total medical cost. These advantages are largely attributed to the elimination of intraoperative repositioning, streamlined trocar placement, and minimized bowel interference. Additionally, a lower incidence of postoperative hypoproteinemia was observed in SRLRNU patients, likely reflecting faster gastrointestinal recovery.\u003c/p\u003e\n\u003cp\u003eUTUC surgery can be performed via two distinct routes. The transperitoneal approach provides a larger operative field that is beneficial for managing larger tumors or those that have invaded adjacent intra-abdominal structures, making it the preferred option in such scenarios[14]. In contrast, the retroperitoneal route offers clearer anatomical landmarks and avoids interference from the intestines, making it especially advantageous for kidney-sparing surgeries in UTUC[15]. By forgoing patient repositioning during the procedure, our center primarily employs the retroperitoneal method. The use of SRLRNU not only achieves effective tumor control but also significantly enhances perioperative outcomes, thereby offering a superior therapeutic alternative for UTUC patients. Furthermore, by reducing the need for intraoperative positional adjustments and shortening the overall operating time, SRLRNU supports the advancement of minimally invasive surgical techniques and underscores its value in clinical.\u003c/p\u003e\n\u003cp\u003eThe SRLRNU method is characterized by shorter operative time, less blood loss, and quicker postoperative recovery. Although similar findings have been reported by others using robot-assisted surgery[16], our data obtained from conventional laparoscopic procedures show that experienced laparoscopic surgeons can complete the procedure in a median time of 115 minutes compared to approximately three hours with robotic assistance. This suggests that while robotic systems may facilitate certain technical aspects such as bladder cuff suturing, proficient laparoscopic techniques can also achieve rapid surgical completion. The results indicate that SRLRNU may be best suited for patients with lower tumor burden or tumors in more accessible locations. By clearly delineating the suitable patient populations for each surgical technique, this study provides valuable guidance for individualized treatment planning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn clinical, urologists frequently opt for the transperitoneal approach for advanced UTUC, especially when imaging shows invasion into surrounding tissues, because the transperitoneal route not only offers a larger operative field for managing complex cases but also is essential when resection of part of the peritoneum becomes necessary[17]. Although patients with locally advanced tumors (T3/T4 or N+) generally have poorer prognoses, it is widely believed that RNU combined with lymphadenectomy can confer a survival benefit[18,19]. However, some studies suggest that systemic treatments such as chemotherapy or immunotherapy may yield better OS outcomes for patients with distant metastases[20]. Unfortunately, there is currently insufficient evidence to determine whether the combination of drug therapy and debulking surgery translates into improved OS. Similarly, while ipsilateral lymphadenectomy may improve survival in locally advanced tumors, its primary role is often to accurately stage the disease and guide adjuvant therapy[21]. There remains a lack of robust prospective, randomized controlled trials to determine both the necessity and the extent of lymph node dissection.\u003c/p\u003e\n\u003cp\u003eKidney-Sparing Surgery (KSS) represents another focus in current UTUC research. For tumors confined to the ureter, options include ureteroureterostomy, distal ureterectomy with reimplantation, and laser ablation[1]. These approaches demand meticulous patient selection and shared decision-making due to uncertainties regarding recurrence[22]. With advancements in surgical instruments and accumulating experience, these procedures can now be performed via laparoscopy or robot-assisted surgery, significantly reducing surgical trauma and enhancing patient acceptance[23]. In our center, laparoscopic ureteroureterostomy is typically performed for ureteral tumors smaller than 2 cm, whereas distal ureterectomy with bladder cuff reimplantation is reserved for tumors located at the distal ureter. Our experience indicates that a spiral-shaped bladder flap generally meets the needs of most reimplantation procedures. For patients with multiple ureteral tumors or those requiring long-segment ureterectomy, we employ one of three approaches: on the right side, an appendiceal substitution is preferred; another option is ileal substitution, usually performed via the transperitoneal route with robotic assistance recommended due to multiple anastomoses; and lastly, a tongue mucosa substitute technique is used, where the thickness of the harvested mucosa is critical for success.\u003c/p\u003e\n\u003cp\u003eFor low-risk UTUC patients, endoscopic management is also an alternative solution[1]. Procedures involving ureteroscopy, flexible ureteroscopy, or percutaneous nephroscopy, combined with laser or cryoablation, can be employed for tumor excision[24]. These methods remain under investigation and require strict adherence to surgical indications, as well as rigorous postoperative surveillance, due to concerns over incomplete resection and potential tumor seeding. Some studies have reported that for low-risk UTUC, endoscopic treatment yields satisfactory OS and RFS[25,26]. Thus, for patients with a high desire to preserve renal function or those with a solitary kidney, ablation techniques are a viable option, provided that patients can commit to stringent follow-up. However, when using a percutaneous approach, there is a risk of tumor fragments descending via irrigation flow into the ureter or bladder[27]. Some researchers have noted recurrence rates of 52% with ureteroscopy for low-grade disease compared to 23% with a percutaneous approach[28]. Despite the direct access provided by a percutaneous tract and the use of larger, more comprehensive instruments, making it more suitable for renal pelvic UTUC resection, the higher rate of severe complications must be considered. In one instance of percutaneous laser resection for UTUC in a patient with an ileal conduit following radical cystectomy, we observed that small tumor fragments were washed down the ureter, raising concerns about subsequent seeding. These factors underscore the necessity of strict adherence to surgical indications, collaborative treatment planning with patients, and rigorous long-term follow-up when choosing this approach.\u003c/p\u003e\n\u003cp\u003eNonetheless, this study has limitations. As a single-center retrospective study with a relatively homogeneous sample, our findings may be subject to selection bias and may not be generalizable. Although the study was conducted under strict quality control, multi-center data would likely offer a more comprehensive comparison of the efficacy of SRLRNU versus TRLRNU. Moreover, despite a collection period of approximately five years, the mean follow-up of 26 months is insufficient to fully assess the long-term survival outcomes of UTUC patients, particularly regarding five-year recurrence and survival rates. The statistically significant differences in cardiovascular comorbidities and tumor locations between the two groups, despite adjustment for these confounders in multivariate analysis, could still potentially influence the interpretation of our results. We advocate for future prospective, randomized controlled trials with larger sample sizes and multi-center participation to validate our conclusions, as well as more in-depth studies based on tumor stage, location, and patient characteristics to provide more precise individualized treatment guidance.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSRLRNU offers a safe and efficient alternative to TRLRNU for appropriately selected UTUC patients, particularly those with localized or surgically favorable tumors. It preserves oncological efficacy while enhancing perioperative recovery and reducing healthcare costs. This study provides valuable clinical evidence supporting SRLRNU as a viable treatment strategy in the evolving landscape of minimally invasive urologic oncology.\u003c/p\u003e"},{"header":"Abbreviation","content":"\u003cp\u003eASA\u0026nbsp; \u0026nbsp;\u0026nbsp;American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp;Body Mass Index\u003c/p\u003e\n\u003cp\u003eCD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Clavien-Dindo Classification\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; Confidence Interval\u003c/p\u003e\n\u003cp\u003eCSS\u0026nbsp; \u0026nbsp; \u0026nbsp;Cancer-Specific Survival\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;Computed Tomography\u003c/p\u003e\n\u003cp\u003eCTU\u0026nbsp; \u0026nbsp;\u0026nbsp;Computed Tomography Urography\u003c/p\u003e\n\u003cp\u003eEAU\u0026nbsp; \u0026nbsp;\u0026nbsp;European Association of Urology\u003c/p\u003e\n\u003cp\u003eeGFR\u0026nbsp; \u0026nbsp;Estimated Glomerular Filtration Rate\u003c/p\u003e\n\u003cp\u003eHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;Hazard Ratio\u003c/p\u003e\n\u003cp\u003eKSS\u0026nbsp; \u0026nbsp; \u0026nbsp;Kidney-Sparing Surgery\u003c/p\u003e\n\u003cp\u003eMRI\u0026nbsp; \u0026nbsp; \u0026nbsp;Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003eOS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;Overall Survival\u003c/p\u003e\n\u003cp\u003ePET/CT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Positron Emission Tomography / Computed Tomography\u003c/p\u003e\n\u003cp\u003ePFS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; Progression-Free Survival\u003c/p\u003e\n\u003cp\u003eRFS\u0026nbsp; \u0026nbsp; \u0026nbsp;Recurrence-Free Survival\u003c/p\u003e\n\u003cp\u003eRNU\u0026nbsp; \u0026nbsp;\u0026nbsp;Radical Nephroureterectomy\u003c/p\u003e\n\u003cp\u003eSAE\u0026nbsp; \u0026nbsp; \u0026nbsp;Serious Adverse Event\u003c/p\u003e\n\u003cp\u003eSRLRNU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Single-position Retroperitoneal Laparoscopic Radical Nephroureterectomy\u003c/p\u003e\n\u003cp\u003eTEAE\u0026nbsp;\u0026nbsp;Treatment-Emergent Adverse Event\u003c/p\u003e\n\u003cp\u003eTRLRNU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Traditional Retroperitoneal Laparoscopic Radical Nephroureterectomy\u003c/p\u003e\n\u003cp\u003eURS\u0026nbsp; \u0026nbsp;\u0026nbsp;Ureteroscopy\u003c/p\u003e\n\u003cp\u003eUTUC Upper Tract Urothelial Carcinoma\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eThe study protocol was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University (Approval No. QYFYEC2023-68).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\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 analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by a grant of the National Natural Science Foundation of China (No.82200759) and supported by the Qingdao Science and Technology Benefit Demonstration Project (No: 24-1-8-smjk-4-nsh)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKai Zhao: Conceptualization, Methodology, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;original draft. Jiao Huang: Data curation, Resources, Investigation, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing.\u0026nbsp;Yuxuan He: Software, Formal analysis, Data curation, Visualization.\u0026nbsp;Bin Dong: Data collection, Investigation, Resources.\u0026nbsp;Rui Zhang: Data collection, Investigation, Data validation.\u0026nbsp;Zongliang Zhang: Methodology, Data collection.\u003c/p\u003e\n\u003cp\u003eXinbao Yin: Visualization, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing. Xiaokun Yang: Formal analysis, Resources. Guoyi Jiang: Methodology. Woong Jin Bae: Methodology, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing.\u0026nbsp;Ke Wang: Supervision, Validation, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing.\u0026nbsp;Guanqun Zhu: Conceptualization, Project administration, Funding acquisition, Supervision, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoupret, M., Seisen, T., Birtle, A. J., Capoun, O., Comperat, E. M., Dominguez-Escrig, J. L., Gurses Andersson, I., Liedberg, F., Mariappan, P., Hugh Mostafid, A., Pradere, B., van Rhijn, B. W. G., Shariat, S. F., Rai, B. P., Soria, F., Soukup, V., Wood, R. G., Xylinas, E. N., Masson-Lecomte, A., \u0026amp; Gontero, P. (2023). 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C., McNeill, S. A., \u0026amp; Tolley, D. A. (2011). Long-term comparative outcomes of open versus laparoscopic nephroureterectomy for upper urinary tract urothelial-cell carcinoma after a median follow-up of 13 years*. \u003cem\u003eJ Endourol\u003c/em\u003e,\u003cem\u003e 25\u003c/em\u003e(8), 1329-1335. https://doi.org/10.1089/end.2011.0223 \u003c/li\u003e\n\u003cli\u003eSoria, F., Shariat, S. F., Lerner, S. P., Fritsche, H. M., Rink, M., Kassouf, W., Spiess, P. E., Lotan, Y., Ye, D., Fernandez, M. I., Kikuchi, E., Chade, D. C., Babjuk, M., Grollman, A. P., \u0026amp; Thalmann, G. N. (2017). Epidemiology, diagnosis, preoperative evaluation and prognostic assessment of upper-tract urothelial carcinoma (UTUC). \u003cem\u003eWorld J Urol\u003c/em\u003e,\u003cem\u003e 35\u003c/em\u003e(3), 379-387. https://doi.org/10.1007/s00345-016-1928-x \u003c/li\u003e\n\u003cli\u003eYamany, T., van Batavia, J., Ahn, J., Shapiro, E., \u0026amp; Gupta, M. (2015). Ureterorenoscopy for upper tract urothelial carcinoma: how often are we missing lesions? \u003cem\u003eUrology\u003c/em\u003e,\u003cem\u003e 85\u003c/em\u003e(2), 311-315. https://doi.org/10.1016/j.urology.2014.08.030 \u003c/li\u003e\n\u003cli\u003eLeow, J. J., Chong, Y. L., Chang, S. L., Valderrama, B. P., Powles, T., \u0026amp; Bellmunt, J. (2021). Neoadjuvant and Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A 2020 Systematic Review and Meta-analysis, and Future Perspectives on Systemic Therapy. \u003cem\u003eEur Urol\u003c/em\u003e,\u003cem\u003e 79\u003c/em\u003e(5), 635-654. https://doi.org/10.1016/j.eururo.2020.07.003 \u003c/li\u003e\n\u003cli\u003eDominguez-Escrig, J. L., Peyronnet, B., Seisen, T., Bruins, H. M., Yuan, C. Y., Babjuk, M., Bohle, A., Burger, M., Comperat, E. M., Gontero, P., Lam, T., MacLennan, S., Mostafid, H., Palou, J., van Rhijn, B. W. G., Sylvester, R. J., Zigeuner, R., Shariat, S. F., \u0026amp; Roupret, M. (2019). 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. \u003cem\u003eEur Urol Focus\u003c/em\u003e,\u003cem\u003e 5\u003c/em\u003e(2), 224-241. https://doi.org/10.1016/j.euf.2017.09.015 \u003c/li\u003e\n\u003cli\u003eZhou, L., Huang, C., Sun, S., Ning, K., \u0026amp; Tang, S. (2025). Kidney sparing surgery versus radical nephroureterectomy in upper tract urothelial carcinoma: a meta-analysis and systematic review. \u003cem\u003eFront Oncol\u003c/em\u003e,\u003cem\u003e 15\u003c/em\u003e, 1448079. https://doi.org/10.3389/fonc.2025.1448079 \u003c/li\u003e\n\u003cli\u003eSeisen, T., Peyronnet, B., Dominguez-Escrig, J. L., Bruins, H. M., Yuan, C. Y., Babjuk, M., Bohle, A., Burger, M., Comperat, E. M., Cowan, N. C., Kaasinen, E., Palou, J., van Rhijn, B. W., Sylvester, R. J., Zigeuner, R., Shariat, S. F., \u0026amp; Roupret, M. (2016). 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. \u003cem\u003eEur Urol\u003c/em\u003e,\u003cem\u003e 70\u003c/em\u003e(6), 1052-1068. https://doi.org/10.1016/j.eururo.2016.07.014 \u003c/li\u003e\n\u003cli\u003eShvero, A., Abu-Ghanem, Y., Laufer, M., Dotan, Z. A., Zilberman, D. E., Mor, Y., Portnoy, O., Fridmen, E., Winkler, H., \u0026amp; Kleinmann, N. (2021). Endoscopic Treatment for Large Multifocal Upper Tract Urothelial Carcinoma. \u003cem\u003eJ Urol\u003c/em\u003e,\u003cem\u003e 205\u003c/em\u003e(4), 1039-1046. https://doi.org/10.1097/JU.0000000000001505 \u003c/li\u003e\n\u003cli\u003eLaukhtina, E., Kawada, T., Quhal, F., Yanagisawa, T., Rajwa, P., von Deimling, M., Pallauf, M., Bianchi, A., Majdoub, M., Enikeev, D., Fajkovic, H., Teoh, J. Y., Roupret, M., Gontero, P., \u0026amp; Shariat, S. F. (2023). Oncologic and Safety Outcomes for Retrograde and Antegrade Endoscopic Surgeries for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis. \u003cem\u003eEur Urol Focus\u003c/em\u003e,\u003cem\u003e 9\u003c/em\u003e(2), 258-263. https://doi.org/10.1016/j.euf.2022.11.014 \u003c/li\u003e\n\u003cli\u003eChen, Y., Xu, C., Mou, Z., Hu, Y., Yang, C., Hu, J., Chen, X., Luo, J., Zou, L., \u0026amp; Jiang, H. (2024). Endoscopic Cryoablation Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. \u003cem\u003eEur Urol Oncol\u003c/em\u003e,\u003cem\u003e 7\u003c/em\u003e(6), 1453-1461. https://doi.org/10.1016/j.euo.2024.04.012 \u003c/li\u003e\n\u003cli\u003ePalou, J., Piovesan, L. F., Huguet, J., Salvador, J., Vicente, J., \u0026amp; Villavicencio, H. (2004). Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup. \u003cem\u003eJ Urol\u003c/em\u003e,\u003cem\u003e 172\u003c/em\u003e(1), 66-69. https://doi.org/10.1097/01.ju.0000132128.79974.db \u003c/li\u003e\n\u003cli\u003eCutress, M. L., Stewart, G. D., Zakikhani, P., Phipps, S., Thomas, B. G., \u0026amp; Tolley, D. A. (2012). Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. \u003cem\u003eBJU Int\u003c/em\u003e,\u003cem\u003e 110\u003c/em\u003e(5), 614-628. https://doi.org/10.1111/j.1464-410X.2012.11068.x \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 2 are available in the Supplementary Files section.\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":"UTUC, nephroureterectomy, retroperitoneal laparoscopy, single-position technique, surgical optimization","lastPublishedDoi":"10.21203/rs.3.rs-8217690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8217690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional retroperitoneal laparoscopic radical nephroureterectomy (TRLRNU) for upper tract urothelial carcinoma (UTUC) requires intraoperative repositioning, increasing operative time and risk. A modified single-position approach (SRLRNU) may improve perioperative efficiency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively analyzed 276 UTUC patients who underwent either SRLRNU (n = 131) or TRLRNU (n = 145) from 2020 to 2024. In SRLRNU, patients remained in a fixed oblique lateral decubitus position throughout, enabling complete nephroureterectomy and bladder cuff excision without repositioning. Detailed surgical steps and port configurations were standardized and are presented in this study. Perioperative and oncologic outcomes were compared between groups. Survival analyses were conducted using Kaplan–Meier and Cox regression models. Subgroup analyses were performed according to tumor stage and pathological characteristics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SRLRNU group showed significantly shorter operative time (124.47 ± 42.54 min vs 160.11 ± 51.43 min, p \u0026lt; 0.001) and reduced blood loss (47.61 ± 140.75 ml vs 71.45 ± 108.42 ml, p \u0026lt; 0.001), without compromising margin status or complication rates. No significant differences were observed in OS, CSS, PFS, or RFS between the two groups (all p \u0026gt; 0.05). Univariable and multivariable analysis suggested T stage, age, and ASA score as independent predictors of OS in the SRLRNU group. Hypoalbuminemia was significantly less frequent in the SRLRNU group (60.31% vs 77.24%, p = 0.002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSRLRNU is a safe and effective alternative to TRLRNU, offering improved perioperative outcomes without compromising long-term cancer control in UTUC patients.\u003c/p\u003e","manuscriptTitle":"Single-Position Versus Traditional Retroperitoneal Laparoscopic Nephroureterectomy for UTUC: Long-Term Survival and Perioperative Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 08:29:45","doi":"10.21203/rs.3.rs-8217690/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-19T06:59:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T01:19:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T10:30:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-14T23:10:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334268281402917170067434832417201416851","date":"2026-01-13T15:15:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-13T14:07:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186046368366645900846544573997417834739","date":"2026-01-13T13:43:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117088495560325532079602959710713617225","date":"2026-01-13T13:34:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286902648419386984625151446744890511536","date":"2026-01-13T13:24:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T13:18:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-09T11:34:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-16T11:55:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-16T11:24:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-12-16T10:42:42+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":"279ce2a3-c922-4270-a460-dd3699e8830a","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:06:38+00:00","versionOfRecord":{"articleIdentity":"rs-8217690","link":"https://doi.org/10.1186/s12894-026-02075-8","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2026-02-13 15:57:53","publishedOnDateReadable":"February 13th, 2026"},"versionCreatedAt":"2026-01-19 08:29:45","video":"","vorDoi":"10.1186/s12894-026-02075-8","vorDoiUrl":"https://doi.org/10.1186/s12894-026-02075-8","workflowStages":[]},"version":"v1","identity":"rs-8217690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8217690","identity":"rs-8217690","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}