Robotic versus laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma: comparable oncologic outcomes with reduced intravesical recurrence in pathological T3 disease

Minimally invasive radical nephroureterectomy (RNU) has been increasingly adopted for upper tract urothelial carcinoma (UTUC); however, direct comparisons between laparoscopic and robot-assisted approaches remain limited. We retrospectively analyzed consecutive patients treated with minimally invasive RNU with bladder cuff excision between August 2014 and July 2025. Patients were stratified into laparoscopic (LNU) and robot-assisted (RANU) groups. Perioperative outcomes and oncologic endpoints, including intravesical recurrence (IVR), disease-free survival (DFS) as well as overall survival (OS), were evaluated. Fine-Gray competing risk regression was applied to assess cancer-specific mortality and IVR. A total of 287 patients were enrolled, comprising 152 in the LNU group and 135 in the RANU group. Perioperative outcomes were comparable between groups, with no significant differences in estimated blood loss, theater time, or major complication rates. During follow-up, no remarkable differences were identified in DFS or OS. Competing risk analysis demonstrated that surgical platform was not significantly correlated with cancer-specific mortality or IVR in the overall cohort. In the subgroup of patients with pathological T3 disease, IVR occurred less frequently in the robotic group compared with the laparoscopic group (7.3% vs. 27.3%, p = 0.016). In exploratory multivariable analysis, robot-assisted surgery was associated with a decreased likelihood of IVR (sHR 0.275, p = 0.041). This finding should be interpreted cautiously in light of the limited sample size and the post-hoc nature of the analysis. Overall, robot-assisted RNU demonstrated perioperative and oncologic outcomes comparable to laparoscopic surgery. The observed difference in IVR in patients with locally advanced disease is hypothesis-generating and warrants further validation in prospective studies.