What is the best treatment for a 70-year-old woman with high-grade urothelial cancer of the kidney pelvis?

Treatment of High-Grade Urothelial Cancer of the Kidney Pelvis in a 70-Year-Old Woman

Radical nephroureterectomy with bladder cuff excision and regional lymphadenectomy is the definitive treatment for high-grade urothelial carcinoma of the renal pelvis. 1

Primary Surgical Management

The gold standard surgical approach consists of:

• Nephroureterectomy with complete bladder cuff excision is mandatory for high-grade tumors to ensure removal of the entire intramural ureter and prevent recurrence at the ureteral orifice 1
• Template-based regional lymph node dissection should be performed in all high-risk disease, as it may improve cancer-specific survival and reduce local recurrence risk 1
• The open surgical approach remains the gold standard, though laparoscopic techniques may be considered for carefully selected cases 2

Critical technical points:

• Complete bladder cuff excision is essential—simplified techniques like the pluck method, stripping, or transurethral resection of the intramural ureter are inferior to complete excision 1
• Lymphadenectomy templates vary by tumor location and should follow anatomic drainage patterns 1
• The completeness of lymph node dissection has greater survival impact than the absolute number of nodes removed 1

Perioperative Systemic Therapy

Adjuvant cisplatin-based chemotherapy is strongly recommended for this patient given the high-grade nature of the tumor 1:

• Patients with pathologic stage pT2, pT3, pT4, or node-positive disease should receive adjuvant chemotherapy 1
• The POUT trial demonstrated improved disease-free survival (HR 0.45) with adjuvant gemcitabine-cisplatin or gemcitabine-carboplatin versus observation in locally advanced upper tract urothelial carcinoma 1
• Cisplatin-based regimens are preferred if the patient has adequate renal function (typically GFR >60 mL/min) 1
• Carboplatin-based regimens may be considered if cisplatin is contraindicated due to renal insufficiency or other comorbidities, though evidence is less robust 1

Neoadjuvant chemotherapy may be considered based on extrapolation from bladder cancer data, particularly if clinical staging suggests locally advanced disease, though this approach has less supporting evidence than adjuvant therapy 1

Adjuvant immunotherapy with nivolumab showed less benefit in upper tract urothelial carcinoma compared to bladder cancer in the CheckMate 274 trial subgroup analysis and is not currently recommended 1

Kidney-Sparing Approaches Are NOT Appropriate

Endoscopic or nephron-sparing surgery should NOT be offered for high-grade renal pelvis tumors 1:

• These approaches are reserved exclusively for low-grade, unifocal tumors <1 cm without invasive features 1, 3
• High-grade tumors carry significantly greater risk of progression after kidney-sparing surgery with direct impact on survival 1
• Even in patients with solitary kidneys or bilateral disease (imperative indications), kidney-sparing approaches for high-grade disease carry substantial progression risk 1

Surveillance Protocol Post-Treatment

Intensive surveillance is required given high recurrence rates:

• Cystoscopy every 3 months for the first year, then every 6 months if negative 1
• Upper tract imaging (CT urography, retrograde pyelogram, or MRI urography) at 1-2 year intervals 1
• Cross-sectional imaging to monitor for metastatic disease, particularly in patients with pT2 or higher stage 1

Important Clinical Considerations

Age-related factors at 70 years:

• No overall differences in safety or effectiveness were observed between elderly patients (≥65 years) and younger patients in urothelial carcinoma trials 4
• Careful assessment of renal function is critical both for surgical planning and chemotherapy eligibility 1
• Chronic kidney disease increases risk of bladder recurrence after nephroureterectomy 5

Common pitfalls to avoid:

• Do not perform incomplete bladder cuff excision—this significantly increases risk of local recurrence 1, 6
• Do not omit lymphadenectomy in high-grade disease, even if nodes appear clinically negative 1
• Do not delay adjuvant chemotherapy beyond 90 days post-surgery when indicated 1
• Do not use kidney-sparing approaches for high-grade tumors outside of absolute imperative indications with full informed consent about progression risk 1