Treatment of Invasive High-Grade Urothelial Carcinoma of the Renal Pelvis
Radical nephroureterectomy with complete bladder cuff excision and regional lymphadenectomy is the definitive treatment for invasive high-grade urothelial carcinoma of the renal pelvis, followed by adjuvant cisplatin-based chemotherapy for pathologic stage pT2 or higher disease. 1, 2
Primary Surgical Management
Radical nephroureterectomy with bladder cuff excision is mandatory for all invasive high-grade tumors of the renal pelvis. 1, 2 This procedure must include:
Complete excision of the entire intramural ureter and bladder cuff to prevent recurrence at the ureteral orifice—simplified techniques like the pluck method, stripping, or transurethral resection of the intramural ureter are inadequate and should not be used. 2
Template-based regional lymph node dissection should be performed in all high-grade disease, as it may improve cancer-specific survival and reduce local recurrence risk. 1, 2
For left-sided renal pelvic tumors, lymphadenectomy should include at minimum the paraaortic lymph nodes from the renal hilum to the aortic bifurcation. 1
For right-sided renal pelvic tumors, lymphadenectomy should include at minimum the paracaval lymph nodes from the renal hilum to the aortic bifurcation. 1
The completeness of lymph node dissection has greater survival impact than the absolute number of nodes removed. 2
Critical Surgical Pitfall to Avoid
Do not perform incomplete bladder cuff excision, as this significantly increases the risk of local recurrence. 2 Do not omit lymphadenectomy even if nodes appear clinically negative on imaging, as complete surgical staging is essential. 2
Perioperative Systemic Therapy
Adjuvant cisplatin-based chemotherapy is strongly recommended for patients with pathologic stage pT2, pT3, pT4, or node-positive disease following nephroureterectomy. 1, 2
The POUT trial demonstrated improved disease-free survival with adjuvant gemcitabine-cisplatin or gemcitabine-carboplatin versus observation in locally advanced upper tract urothelial carcinoma. 2
Cisplatin-based regimens are preferred if the patient has adequate renal function (typically creatinine clearance ≥60 mL/min). 2, 3
Carboplatin-based regimens may be considered if cisplatin is contraindicated due to renal insufficiency or other comorbidities, though evidence is less robust. 2
Do not delay adjuvant chemotherapy beyond 90 days post-surgery when indicated, as this may compromise efficacy. 2
Renal Function Considerations
Careful assessment of renal function is critical both for surgical planning and chemotherapy eligibility, as nephroureterectomy leaves the patient with a solitary kidney. 2, 4 The high incidence of renal insufficiency after surgery substantially limits the applicability of adjuvant chemotherapy with cisplatin-based regimens. 4
Neoadjuvant chemotherapy should be considered in select patients with high-grade disease, as it offers practical advantages including better patient tolerance when both kidneys are present and provides prognostic information from pathological downstaging. 1, 4
Kidney-Sparing Approaches Are Contraindicated
Endoscopic or nephron-sparing surgery should NOT be offered for high-grade renal pelvis tumors. 2 These approaches are reserved exclusively for low-grade, unifocal tumors <1 cm without invasive features. 1, 2
High-grade tumors carry significantly greater risk of progression after kidney-sparing surgery with direct impact on survival. 2
Kidney-sparing approaches should only be considered in the absolute imperative indication of a solitary kidney with full informed consent about progression risk. 1, 2
Post-Treatment Surveillance Protocol
Intensive surveillance is required given high recurrence rates in upper tract urothelial carcinoma:
Cystoscopy every 3 months for the first year, then every 6 months if negative, as bladder recurrence occurs in up to 50% of patients. 1, 2, 5
Upper tract imaging (CT urography or MRI urography) at 1-2 year intervals to monitor the contralateral upper tract. 1, 2
Cross-sectional imaging to monitor for metastatic disease, particularly in patients with pT2 or higher stage disease. 2
Prognostic Considerations
Ureteral tumor location, particularly when associated with multifocal disease in the renal pelvis, is significantly associated with increased risk of disease recurrence and cancer-specific death after surgery. 6
Stage, grade, and lymphovascular invasion are the most powerful predictors of survival in upper tract urothelial carcinoma. 6, 7
The 5-year cancer-specific survival for upper tract urothelial carcinoma is approximately 75%, though this varies significantly by stage and grade. 7