Consultation on UTUC, Stockholm 2018 aspects of risk stratification: long-term results and follow-up

Abstract

PurposeTo summarize current knowledge on upper urinary tract carcinoma (UTUC) regarding risk stratification, long-term results, and follow-up.MethodsA scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC, September 2018, Stockholm.ResultsTo optimize oncological outcome considering both cancer-specific survival (CSS) and overall survival (OS), it is essential to identify pre- and postoperative prognostic factors. In low-risk UTUC, kidney-sparing surgery (KSS) and radical nephroureterectomy (RNU) offer equivalent CSS, whereas RNU may result in poorer OS due to nephron loss. For more aggressive tumours, undergrading can lead to insufficient treatment. The strongest prognostic factors are tumour stage and grade. Determining grade is best achieved by ureterorenoscopy (URS) with focal samples, biopsy and cytology. Staging is more difficult but can be indirectly achieved by multiphase computed tomography urography (CTU) or tumour grade determined by cytology and histopathology. Patients treated with KSS should be monitored closely with regular follow-ups (URS and CTU).ConclusionKSS should be offered in low-risk UTUC when feasible, whereas RNU is the treatment of choice in organ-confined high-risk UTUC. Intravesical recurrence (IVR) is common after RNU, but a single postoperative dose of mitomycin instillation decreases IVR. Endourological management has high local and bladder recurrence rates; however, its effect on CSS or overall survival OS is unclear. RNU is associated with significant risk of chronic kidney disease. Careful selection of patients and risk stratification are mandatory, and patients should be followed according to strict protocols.

Oncological impact of different distal ureter managements during radical nephroureterectomy for primary upper urinary tract urothelial carcinoma

“…While beyond the remit of this study, we would encourage complementary qualitative research into the experiential elements involved in healthcare seeking behaviors related to this disease. While adjuvant therapies such as radiotherapy and chemotherapy may significantly improve overall survival[ 1 , 22 , 23 ], we must balance the system to reduce perceived social stigma and encourage early identification which will improve overall outcomes[ 23 ].…”

Pharmacokinetics of UGN-101, a mitomycin-containing reverse thermal gel instilled via retrograde catheter for the treatment of low-grade upper tract urothelial carcinoma

“…Upper tract urothelial carcinoma (UTUC) is a rare malignancy, most commonly diagnosed in male patients > 70 years of age [ 1 ]. Current European Association of Urology (EAU) guidelines divide UTUC into low- and high-risk disease [ 2 ], with the goal of optimizing treatment based on both patient and tumor characteristics [ 3 ]. Radical nephroureterectomy (RNU) is considered the standard of care for treatment of organ-confined high-risk UTUC [ 3 ], but kidney-sparing surgery, such as endoscopic ablation, increasingly has been used for a subset of UTUC patients with low-grade, non-invasive disease manifesting as a small (< 20 mm), solitary, and favorably located lesion [ 2 , 4 ].…”

“…Current European Association of Urology (EAU) guidelines divide UTUC into low- and high-risk disease [ 2 ], with the goal of optimizing treatment based on both patient and tumor characteristics [ 3 ]. Radical nephroureterectomy (RNU) is considered the standard of care for treatment of organ-confined high-risk UTUC [ 3 ], but kidney-sparing surgery, such as endoscopic ablation, increasingly has been used for a subset of UTUC patients with low-grade, non-invasive disease manifesting as a small (< 20 mm), solitary, and favorably located lesion [ 2 , 4 ]. Endoscopic management of UTUC, however, is associated with a high rate of tumor recurrence [ 4 ], and efforts to improve outcomes using intracavitary instillation of adjuvant chemotherapy have met with limited success [ 5 ], presumably due to the short dwell times achieved in the upper tract when using aqueous solutions that are continuously diluted by urine flow [ 4 , 5 ].…”

Impact of nephron sparing surgery on survival in upper urinary tract urothelial carcinoma patients stratified by tumor characteristics

“…Although the stage of UTUC is usually determined by endoscopic biopsy during ureteroscopy, inadequate tissue sampling and concerns about ureteral perforation make accurate staging challenging [8,9] . Therefore, due to concerns of cancer progression, many clinicians are willing to perform radical eradication therapy even in patients with early-stage UTUC [10,11] .…”