Operative approaches and outcomes of nephroureterectomy for UTUC: a network meta-analysis.

For upper tract urothelial carcinoma (UTUC), the comparative effectiveness of open (ONU), hand-assisted laparoscopic (HALNU), laparoscopic (LNU), and robotic nephroureterectomy (RNU) remains debated. We performed a network meta-analysis to compare their perioperative safety, oncologic outcomes, and efficiency. Three databases were searched through August 11, 2025. A frequentist network analysis was performed (ONU as reference). Primary outcomes were 5-year overall survival (OS), cancer-specific survival (CSS), major complications, and mortality. Secondary outcomes included bladder/intravesical recurrence-free survival (BRFS), recurrence-free survival (RFS), progression-free survival (PFS), metastasis-free survival (MFS), positive surgical margins (PSM), estimated blood loss (EBL), operative time, and length of stay (LOS). Treatments were ranked using SUCRA. Eighty-eight studies involving 70,783 patients were included. Minimally invasive approaches were associated with lower perioperative morbidity compared with ONU. Major complications were reduced with LNU and RNU, and mortality was lower with RNU and LNU. Minimally invasive techniques had lower EBL and shorter LOS, although operative times were longer. Across oncologic outcomes, most pairwise comparisons demonstrated overlapping confidence intervals. Five-year survival outcomes did not differ between approaches. RNU showed favorable estimates for OS and BRFS versus ONU, but these findings were not consistently significant. PSM rates were similar across techniques. SUCRA rankings generally favored RNU for perioperative safety outcomes. Minimally invasive techniques, especially RNU, are associated with improved perioperative safety and recovery compared with open surgery, while long-term oncologic outcomes appear broadly comparable across techniques. These findings are however limited by the observational nature of available evidence, warranting further validation.