Anatomical distribution and predictors of lymph node metastasis in robot-assisted radical nephroureterectomy for upper tract urothelial carcinoma: a multicenter study by the Junior ERUS/YAU Robotic Surgery Working Group
Di Maida, Fabrizio Lambertini, Luca Bravi, Carlo Andrea De Groote, Ruben Piramide, Federico Turri, Filippo Wenzel, Mike Sharma, Gopal Würnschimmel, Christoph Lambert, Edward
Di Maida, Fabrizio
Lambertini, Luca
Bravi, Carlo Andrea
De Groote, Ruben
Piramide, Federico
Turri, Filippo
Wenzel, Mike
Sharma, Gopal
Würnschimmel, Christoph
Lambert, Edward
Abstract
Introduction
The role of lymph node dissection (LND) during robot-assisted nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains debated, particularly in clinically node-negative (cN0) patients. This study aimed to evaluate the anatomical distribution of nodal metastases, identify predictors of lymph node positivity, and assess perioperative and oncological outcomes associated with LND.
Methods
A retrospective multicenter study was conducted including 511 patients treated with RNU for UTUC at multiple high-volume international referral centers between 2019 and 2023. Among them, 218 (42.7%) underwent LND, including 159 with cN0 disease. Multivariable logistic regression identified predictors of nodal positivity. To assess the impact of LND on oncologic outcomes, multivariable Cox proportional hazards models were fitted for metastasis-free survival (MFS), adjusting for clinically relevant covariates.
Results
Patients undergoing LND were younger and had larger tumors. LND was associated with longer operative time and a higher rate of major complications (6.9% vs 1.7%). Adverse pathological features (pT ≥ 2, necrosis, lymphovascular invasion) were more common in the LND group. Among cN0 patients, 17.6% harbored occult nodal metastases. Hilar and iliac–obturator fields yielded the highest positivity rates, while retrocaval and presacral dissections showed none. Larger clinical tumor size was the only independent preoperative predictor of pN + (OR 1.008 per mm; 95% CI 1.002–1.017; p = 0.001). Kaplan–Meier analysis showed improved MFS in cN0 patients treated with LND (p = 0.045), whereas RFS and OS did not differ between groups. In the multivariable Cox model, LND showed a non-significant trend toward reduced metastatic progression, while cT3 stage was strongly associated with worse MFS.
Conclusions
LND during RNU enhances staging accuracy and identifies a clinically relevant proportion of occult metastases in cN0 UTUC patients. Tumor size is the key preoperative predictor of nodal positivity. Although LND improves MFS in unadjusted analyses, its independent therapeutic effect remains uncertain. These findings support a selective, risk-adapted approach to LND that integrates tumor size and anatomical drainage patterns.
MIDER Authors
Affiliations
Date
2026-04-11
Type
Article
Collections
Citation
Di Maida F, Lambertini L, Bravi CA, De Groote R, Piramide F, Turri F, Wenzel M, Sharma G, Würnschimmel C, Lambert E, Dell'Oglio P, Moschovas MC, Campi R, Grosso AA, Liakos N, Mayr R, Darlington D, Eraky A, Paciotti M, Sorce G, Tappero S, Mottaran A, Larcher A, Montorsi F, Briganti A, Crisan N, Mottrie A, Minervini A, Breda A, Andras I. Anatomical distribution and predictors of lymph node metastasis in robot-assisted radical nephroureterectomy for upper tract urothelial carcinoma: a multicenter study by the Junior ERUS/YAU Robotic Surgery Working Group. World J Urol. 2026 Apr 11;44(1):292. doi: 10.1007/s00345-026-06371-8.