From the Guidelines
For a patient with high-grade upper tract urothelial carcinoma (UTUC) in the renal pelvis with two functioning kidneys, radical nephroureterectomy (RNU) with bladder cuff excision is the recommended treatment. This approach is based on the most recent and highest quality evidence, which suggests that high-risk UTUC patients should undergo open or laparoscopic radical nephroureterectomy with bladder cuff excision regardless of tumor location [ 1 ].
Key Considerations
- High-grade UTUCs have a poor prognosis, with a 5-year cancer-specific survival of <50% for patients with pT2-pT3 tumors and <10% for those with pT4 [ 1 ].
- Kidney-sparing management, such as endoscopic laser ablation, is generally recommended for low-risk UTUC, but not for high-risk tumors [ 1 ].
- The decision between RNU and kidney-sparing approaches should be individualized based on tumor characteristics, renal function, and patient comorbidities.
Treatment Options
- Radical nephroureterectomy (RNU) with bladder cuff excision is the standard of care for high-grade UTUC [ 1 ].
- Kidney-sparing surgery might be considered in select cases, such as solitary kidney, bilateral tumors, chronic kidney disease, or patients who cannot tolerate radical surgery [ 1 ].
- Adjuvant therapy with intracavitary BCG or mitomycin C may be used following kidney-sparing procedures, but its role is not well established in UTUC [ 1 ].
Surveillance and Follow-up
- Close surveillance is mandatory for patients undergoing kidney-sparing approaches, with frequent ureteroscopy, cytology, and imaging [ 1 ].
- The goal of surveillance is to detect recurrence or progression early, when it is more amenable to treatment [ 1 ].
From the Research
Treatment Options for Upper Tract Urothelial Carcinoma (UTUC)
- Radical nephroureterectomy (RNU) is still the gold-standard treatment for high-risk UTUC, but kidney-sparing surgery is a viable option for patients with low-risk disease or those with a single functioning kidney 2, 3, 4, 5, 6.
- Kidney-sparing surgery includes segmental ureterectomy, endoscopic ablation, chemoablation, and vascular-targeted phototherapy, with endoscopic laser ablation being a recommended treatment for favorable low-grade disease 3.
- The main limitations of kidney-sparing surgery are appropriate tissue sampling, higher rates of ipsilateral recurrence, and potential for grade and stage progression, which may necessitate RNU 3, 4, 5.
Considerations for Patients with Two Functioning Kidneys
- For patients with two functioning kidneys, kidney-sparing surgery can be considered for low-risk UTUC, but the decision should be made on a case-by-case basis, taking into account the patient's overall health, tumor characteristics, and personal preferences 4, 6.
- The discussion with the patient about the advantages and drawbacks of both approaches, and their perspective on quality of life, are key points for selecting the therapeutic approach 2.
Emerging Trends and Future Directions
- Newer investigations, such as narrow band imaging or photodynamic diagnosis with ureteroscopy, may improve visualization during diagnosis and treatment, and genomic characterization may improve selection for kidney-sparing surgery 6.
- The evolution of adjuvant management, including strategies to increase the dwell time and urothelial contact of intraluminal agents, and the use of chemoablation using a hydrogel, may further improve kidney preservation in UTUC 6.