From the Guidelines
Kidney-sparing management, such as endoscopic laser ablation, should be offered as the primary treatment option to patients with low-risk upper tract urothelial carcinoma (UTUC) of the renal pelvis. This approach is supported by the latest research findings, including the 2022 ESMO clinical practice guideline for diagnosis, treatment, and follow-up of bladder cancer, which also addresses UTUC 1. According to this guideline, low-risk tumours include unifocal tumours of <1 cm, low-grade disease at cytology/biopsy, and no invasive features on CT urography.
Key Considerations for Low-Risk UTUC
- Low-risk tumours are typically characterized by unifocal tumours of <1 cm, low-grade disease at cytology/biopsy, and no invasive features on CT urography 1.
- The presence of concomitant CIS of the upper tract is between 11% and 36%, and multifocal tumours are found in 10%-20% of UTUC cases 1.
- The most common symptom is haematuria (70%-80%) or flank pain (10%-20%) 1.
Treatment Approach
- Endoscopic laser ablation is recommended as the primary treatment option for patients with low-risk UTUC 1.
- High-risk UTUC patients should undergo open or laparoscopic radical nephroureterectomy with bladder cuff excision regardless of tumour location 1.
- Systemic therapy for advanced disease should follow the recommendations for urothelial bladder cancer, including adjuvant cisplatin-based chemotherapy 1.
Surveillance and Follow-Up
- Close surveillance is essential following treatment, with ureteroscopy and cytology recommended every 3 months for the first year, every 6 months for the second year, and annually thereafter.
- CT urography should be performed annually to monitor for recurrence or progression 1.
From the Research
Treatment Options for Low-Grade Upper Tract Urothelial Carcinoma (UTUC)
- Endoscopic management, including ureteroscopic and percutaneous resection, is a treatment option for selected low-grade UTUC tumors with favorable characteristics 2, 3, 4, 5.
- The standard treatment for UTUC is radical nephroureterectomy (RNU), but endoscopic management can provide renal preservation in experienced centers 2, 3, 4, 6.
Prognostic Factors
- Tumor grade, location, and size are significant prognostic factors for UTUC recurrence and progression 3, 4.
- History of bladder tumor and tumor stage are also prognostic factors for overall survival 4.
- The recurrence rate for low-grade tumors is lower compared to high-grade tumors 3, 4.
Outcomes of Endoscopic Management
- The 5-year disease-specific survival (DSS) rate for low-grade UTUC treated with endoscopic management can be equivalent to RNU in highly selected patients 2, 5.
- Upper tract recurrence is common, and regular ureteroscopic surveillance is necessary 3, 4, 5.
- The estimated 5-year DSS rate for endoscopically managed UTUC is around 88.9%, and the 10-year DSS rate is around 77.4% 5.