European Urology

Radical nephroureterectomy (RNU) with excision of the bladder cuff is the treatment of choice for high-risk non-invasive and invasive upper tract urothelial carcinoma [1]. With the diffusion of laparoscopy over the last two decades, laparoscopic RNU (LNU) has gained increasing popularity compared to open RNU (ONU).

Recently, a propensity-score-matched analysis [2] and a systematic review (with cumulative analysis) of available comparative studies [3] suggested that some intra- and perioperative outcomes were more favorable in patients treated with LNU compared with ONU. Specifically, LNU patients were less likely to require a blood transfusion and/or to experience intraoperative complications and had a shorter length of stay. These considerations could be important from a patient's perspective as well as a system's perspective (eg, resource allocation, cost effectiveness). In addition to the potentially improved perioperative outcomes, LNU seems noninferior to ONU with regard to midterm oncologic outcomes [3] and [4]. Although there are no well-powered prospective trials evaluating the long-term outcomes of LNU versus ONU, LNU has been widely adopted by the urologic community.

In the present study, we aimed to report the national practice patterns of LNU and ONU in France, relying on the data from the Programme de médicalisation des systèmes d’information (PMSI) database from the French national health insurance program. We obtained yearly numbers of RNUs performed between 2003 and 2011 from the French national PMSI database. All performed surgical interventions are registered in France regardless of the health care center, making the PMSI database reliable and complete. Data are anonymized and are regularly controlled by a national agency.

The total number of RNUs remained consistent between 2003 and 2011, with approximately 1800 RNUs performed per year. The number of LNUs increased slowly but steadily until it surpassed the number of ONUs in 2010 (Fig. 1). Interestingly, 45% of the RNUs in 2011 were still performed by the open approach. The rates of LNU uptake in public (academic centers) and private-practice hospitals were similar, with private-practice hospitals showing a slightly faster uptake. In 2011, the public hospitals performed 45% of the RNUs, and 55% of the RNUs in France were performed in private-practice hospitals. No difference was reported between geographic regions in France, as laparoscopic devices have been widely distributed throughout the country.

Fig. 1 Number of radical nephroureterectomies performed in France between 2003 and 2011. LNU = laparoscopic radical nephroureterectomy; ONU = open radical nephroureterectomy.

Despite a growing popularity of LNU, ONU is still commonly performed in France. In 2010, LNU became the preferred approach for RNU in France. Currently, the rates of LNU and ONU are similar for public and private hospitals. Although the approach to the upper tract may not matter with regard to outcomes, approach to the distal ureter cuff is important, especially in terms of intravesical recurrence [5]. Moreover, lymphadenectomy is an important surgical step during RNU. In addition to lymph node (LN) status, the extent of lymphadenectomy, the number of LNs examined, the number of positive LNs detected, and the LN density have been suggested to have both prognostic and potentially therapeutic implications [6] and [7]. Consequently, knowledge of the true LN status is important because it influences patient counseling and, more important, clinical decision making regarding follow-up scheduling and adjuvant chemotherapy. Therefore, LNU has to fulfill the same oncologic principles as ONU. Taken together, these data should encourage practitioners from other countries to publish their results to appreciate the evolution and disparities of surgical approaches.

Conflicts of interest

The authors have nothing to disclose.