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Upper urinary tract urothelial carcinoma

What's new

Updated 2023 JUA guidelines for the diagnosis and management of upper urinary tract urothelial carcinoma.

Guidelines

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 Japanese Urological Association (JUA 2024), the American Urological Association (AUA/SUO 2023), the European Association of Urology (EAU 2023), and the American Urological Association (AUA 2021). ...
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Classification and risk stratification

Risk assessment: as per EAU 2023 guidelines, use prognostic factors to risk-stratify patients for therapeutic guidance.
B
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Diagnostic investigations

Clinical assessment
As per EAU 2023 guidelines:
Elicit a medical and family history based on the Amsterdam criteria to identify patients with UTUC.
B
Elicit a history of exposure to smoking and aristolochic acid.
B

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  • Diagnostic imaging

  • Laboratory testing

Diagnostic procedures

Diagnostic endoscopy: as per JUA 2024 guidelines, consider performing ureteroscopic tumor biopsy only when imaging and urine cytology are inadequate for diagnosis.
C

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  • Urinary tract washing

  • Histopathology

Medical management

Watchful waiting: as per AUA/SUO 2023 guidelines, 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

Therapeutic procedures

Kidney-sparing interventions
As per EAU 2023 guidelines:
Offer kidney-sparing management as the primary treatment in patients with low-risk tumors.
A
Offer kidney-sparing management in high-risk patients with imperative indication on a case-by-case basis, in consultation with the patient.
A

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  • Pelvicalyceal chemotherapy

  • Pelvicalyceal BCG

Surgical interventions

Radical nephroureterectomy: as per JUA 2024 guidelines, consider performing laparoscopic or robot-assisted surgery for total nephroureterectomy.
C

Patient education

General counseling
As per AUA/SUO 2023 guidelines:
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.
B
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

Follow-up and surveillance

Surveillance after kidney-sparing management
As per EAU 2023 guidelines:
Perform cystoscopy and obtain CT urography at 3 and 6 months and then yearly for 5 years in low-risk patients. Perform ureteroscopy at 3 months if no second-look ureteroscopy was performed.
B
Perform ureteroscopy and urinary cytology in situ at 3 and 6 months in high-risk patients.
B

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  • Surveillance after nephroureterectomy