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Upper urinary tract urothelial carcinoma

Key sources
The following summarized guidelines for the evaluation and management of upper urinary tract urothelial carcinoma are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the American Urological Association (AUA/SUO 2023), the Japanese Urological Association (JUA 2023), and the American Urological Association (AUA 2021).
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Guidelines

1.Classification and risk stratification

Risk assessment
As per AUA 2023 guidelines:
Obtain a standardized assessment documenting clinically meaningful endoscopic (focality, location, appearance, size) and radiographic (invasion, obstruction, and lymphadenopathy) features to facilitate clinical staging and risk assessment at the time of identified UTUC.
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Stratify patients as low or high risk for invasive disease (≥ pT2) following standardized assessment based on obtained endoscopic, cytologic, pathologic, and radiographic findings. Obtain further stratification into favorable and unfavorable risk groups based on standard identified features.
B
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2.Diagnostic investigations

Clinical assessment: as per AUA 2023 guidelines, elicit a personal and family history to identify known hereditary risk factors for familial diseases associated with Lynch syndrome (colorectal, ovarian, endometrial, gastric, biliary, small bowel, pancreatic, prostate, skin, and brain cancer) in patients with suspected/diagnosed UTUC, and offer referral for genetic counseling if identified.
E

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  • Diagnostic imaging

  • Laboratory testing

3.Diagnostic procedures

Diagnostic endoscopy: as per AUA 2023 guidelines, perform cystoscopy in patients with suspected UTUC.
B
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  • Urinary tract washing

  • Histopathology

4.Medical management

Watchful waiting: consider offering watchful waiting or surveillance alone in selected patients with upper tract urothelial carcinoma with significant comorbidities, competing risks of mortality, or significant risk of ESRD with any intervention resulting in dialysis.
E

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  • Neoadjuvant therapy

  • Adjuvant therapy (platinum-based)

  • Adjuvant therapy (nivolumab)

  • Definitive therapy (first-line therapy)

  • Definitive therapy (second-line therapy)

  • Definitive therapy (subsequent-line therapy)

  • Definitive therapy (maintenance therapy)

  • Palliative care

5.Therapeutic procedures

Kidney-sparing interventions: as per AUA 2023 guidelines, perform tumor ablation as the initial management option in patients with low-risk favorable UTUC.
B
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  • Pelvicalyceal chemotherapy

  • Pelvicalyceal BCG

6.Surgical interventions

Radical nephroureterectomy: as per AUA 2023 guidelines, assess for the risk of post-nephroureterectomy CKD or dialysis before surgery in patients with UTUC.
E
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7.Patient education

General counseling
Provide patients with a description of the short- and long-term risks associated with recommended diagnostic and therapeutic options, including the need for endoscopic follow-up, clinically significant strictures, toxicities associated with surgical treatment, and side effects from neoadjuvant and adjuvant therapies.
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Discuss disease-related stresses and risk factors and encourage patients with urothelial cancer to adopt healthy lifestyle habits, including smoking cessation, exercise, and a healthy diet, to promote long-term health benefits and QoL.
E

8.Follow-up and surveillance

Surveillance after kidney-sparing management: as per AUA 2023 guidelines, perform a follow-up cystoscopy and upper urinary tract endoscopy within 1-3 months to confirm successful treatment in low-risk patients managed with kidney-sparing treatment. Obtain continued cystoscopic surveillance of the bladder, once successful treatment is confirmed, at least every 6-9 months for the first 2 years and at least annually thereafter. Repeat endoscopy at 6 months and 1 year. Obtain upper urinary tract imaging at least every 6-9 months for 2 years, then annually for up to 5 years. Obtain surveillance after 5 years in the absence of recurrence based on shared decision-making between the patient and clinician.
E
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  • Surveillance after nephroureterectomy