Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma

Publication Date: April 25, 2023
Last Updated: April 26, 2023

Diagnosis and Evaluation

For patients with suspected UTUC, a cystoscopy and cross- sectional imaging of the upper tract with contrast including delayed images of the collecting system and ureter should be performed. (Strong, B)
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Clinicians should evaluate patients with suspected UTUC with diagnostic ureteroscopy and biopsy of any identified lesion and cytologic washing from the upper tract system being inspected. (Strong, C)
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In patients who have concomitant lower tract tumors (bladder/urethra) discovered at the time of ureteroscopy, the lower tract tumors should be managed in the same setting as ureteroscopy. (Expert Opinion, )
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In cases of existing ureteral strictures or difficult access to the upper tract, clinicians should minimize risk of ureteral injury by using gentle dilation techniques such as temporary stenting (pre-stenting) and limit use of aggressive dilation access techniques such as ureteral access sheaths. (Expert Opinion, )
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In cases where ureteroscopy cannot be safely performed or is not possible, an attempt at selective upper tract washing or barbotage for cytology may be made and pyeloureterography performed in cases where good quality imaging such as CT or MR urography cannot be obtained. (Conditional, C)
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At the time of ureteroscopy for suspected UTUC, clinicians should not perform ureteroscopic inspection of a radiographically and clinically normal contralateral upper tract. (Expert Opinion, )
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For patients with suspected/ diagnosed UTUC, clinicians should obtain a personal and family history to identify known hereditary risk factors for familial diseases associated with Lynch Syndrome (LS) (colorectal, ovarian, endometrial, gastric, biliary, small bowel, pancreatic, prostate, skin and brain cancer) for which referral for genetic counseling should be offered. (Expert Opinion, )
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Universal histologic testing of UTUC with additional studies, such as immunohistochemical (IHC) or microsatellite instability (MSI), should be performed to identify patients with high probability of Lynch-related cancers whom clinicians should refer for genetic counseling and germline testing. (Strong, B)
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Risk Stratification

At the time of identified UTUC, clinicians should perform 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. (Strong, B)
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Following standardized assessment, clinicians should risk-stratify patients as “low-” or “high” risk for invasive disease (pT2 or greater) based on obtained endoscopic, cytologic, pathologic, and radiographic findings. Further stratification into favorable and unfavorable risk groups should then be based on standard identified features (Table 5). (Strong, B)
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Patients with UTUC should be assessed prior to surgery for the risk of post-NU CKD or dialysis. (Expert Opinion, )
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Treatment

Clinicians should provide patients with a description of the short- and long-term risks associated with recommended diagnostic and therapeutic options. This includes the need for endoscopic follow-up, clinically significant strictures, toxicities associated with surgical treatment and side effects from neoadjuvant and adjuvant therapies. (Clinical Principle, )
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Kidney Sparing Management

Tumor ablation should be the initial management option for patients with LR favorable UTUC. (Strong, B)
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Tumor ablation may be the initial management option offered to patients with LR unfavorable UTUC and select patients with HR favorable disease who have low-volume tumors or cannot undergo RNU. (Conditional, C)
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Tumor ablation may be accomplished via a retrograde or antegrade percutaneous approach and repeat endoscopic evaluation should be performed within three months. (Expert Opinion, )
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Following ablation of UTUC tumors and after confirming there is no perforation of the bladder or upper tract
clinicians may instill adjuvant pelvicalyceal chemotherapy (Conditional, C)
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intravesical chemotherapy (Expert Opinion, )
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to decrease the risk of urothelial cancer recurrence.
Pelvicalyceal therapy with BCG may be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS). (Expert Opinion, )
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When tumor ablation is not feasible or evidence of risk group progression is identified in patients with LR UTUC, surgical resection of all involved sites either by RNU or segmental resection of the ureter should be offered. (Moderate, C)
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Clinicians may offer watchful waiting or surveillance alone to select patients with UTUC with significant comorbidities, competing risks of mortality, or at significant risk of End-Stage Renal Disease (ESRD) with any intervention resulting in dialysis. (Expert Opinion, )
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Surgical Management

Clinicians should recommend RNU or SU for surgically eligible patients with HR UTUC. (Strong, B)
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For surgically eligible patients with HR and unfavorable LR cancers endoscopically confirmed as confined to the lower ureter in a functional renal unit, distal ureterectomy and ureteral reimplantation is the preferred treatment. (Expert Opinion, )
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When performing NU or distal ureterectomy, the entire distal ureter including the intramural ureteral tunnel and ureteral orifice should be excised, and the urinary tract should be closed in a watertight fashion. (Strong, B)
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In patients undergoing RNU or SU (including distal ureterectomy) for UTUC, a single dose of perioperative intravesical chemotherapy should be administered in eligible patients to reduce the risk of bladder recurrence. (Strong, A)
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Lymph Node Dissection

For patients with LR UTUC, clinicians may perform LND at time of NU or ureterectomy. (Conditional, C)
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For patients with HR UTUC, clinicians should perform LND at the time of NU or ureterectomy. (Strong, B)
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Neoadjuvant Chemotherapy and Immunotherapy

Clinicians should offer cisplatin-based NAC to patients undergoing RNU or ureterectomy with HR UTUC, particularly in those patients whose post-operative eGFR is expected to be less than 60 mL/min/1.73m2 or those with other medical comorbidities that would preclude platinum-based chemotherapy in the post-operative setting. (Strong, B)
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Clinicians should offer platinum-based adjuvant chemotherapy to patients with advanced pathological stage (pT2–T4 pN0–N3 M0 or pTany N1–3 M0) UTUC after RNU or ureterectomy who have not received neoadjuvant platinum-based therapy. (Strong, A)
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Adjuvant nivolumab therapy may be offered to patients who received neoadjuvant platinum-based chemotherapy (ypT2–T4 or ypN+) or who are ineligible for or refuse perioperative cisplatin (pT3, pT4a, or pN+). (Conditional, B)
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In patients with metastatic (M+) UTUC, RNU or ureterectomy should not be offered as initial therapy. (Expert Opinion, )
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Patients with clinical, regional node-positive (cN1-3, M0) UTUC should initially be treated with systemic therapy. Consolidative RNU or ureterectomy with lymph-node dissection may be performed in those with a partial or complete response. (Expert Opinion, )
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Patients with unresectable UTUC (including those who are ineligible or refuse surgery [RNU or ureterectomy]) should be offered a clinical trial or best supportive care including palliative management (radiation, systemic approach, endoscopic, or ablative) for refractory symptoms such as hematuria. (, )
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Surveillance and Survivorship

Low-risk patients managed with kidney sparing treatment should undergo a follow-up cystoscopy and upper tract endoscopy within one to three months to confirm successful treatment. Once confirmed, these patients should undergo continued cystoscopic surveillance of the bladder at least every six to nine months for the first two years and then at least annually thereafter. Endoscopy should be repeated at six months and one year. Upper tract imaging should be performed at least every six to nine months for two years, then annually up to five years. surveillance after five years in the absence of recurrence should be based on shared decision-making between the patient and clinician. (Expert Opinion, )
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High-risk patients managed with kidney sparing treatment should undergo a follow-up cystoscopy and upper tract endoscopy with cytology within one to three months. Patients with no evidence of disease should undergo cystoscopic surveillance of the bladder and cytology at least every three to six months for the first three years and then at least annually thereafter. Endoscopy should be repeated at least at six months and one year. Upper tract imaging should be performed every three to six months for three years, then annually up to five years. surveillance after five years in the absence of recurrence should be encouraged and based on shared decision-making between the patient and clinician. (Expert Opinion, )
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Patients who develop urothelial recurrence in the bladder or urethra or positive cytology following treatment for UTUC should be evaluated for possible ipsilateral recurrence or development of new contralateral upper tract disease. (Expert Opinion, )
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After NU, patients with <pT2 N0/M0 disease should undergo surveillance with cystoscopy and cytology within three months after surgery, then repeated based on pathologic grade. For LG this should repeated at least every six to nine months for the first two years and then at least annually thereafter. For HG, this should be repeated at least every three to six months for the first three years and then at least annually thereafter. Due to the metastasis risk and estimated 5% probability for contralateral disease, cross-sectional imaging of the abdomen and pelvis should be done within 6 months after surgery and then at least annually for a minimum of 5 years. Surveillance after five years in the absence of recurrence should be encouraged and based on shared decision-making between the patient and clinician. (Expert Opinion, )
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For Patients who have undergone NU for >pT2 Nx/0 disease, a clinician should perform surveillance cystoscopy with cytology at three months after surgery, then every three to six months for 3 years, and then annually thereafter. Cross-sectional imaging of the abdomen and pelvis with multiphasic contrast-enhanced CT urography should be performed every three to six months for years one and two, every six months at year three, and annually thereafter to year five. A clinician should perform chest imaging, preferably with chest CT, every 6-12 months for the first 5 years. Beyond five years after surgery in patients without recurrence, ongoing surveillance with cystoscopy and upper tract imaging may be continued on an annual basis according to principles of shared/informed decision-making. (Expert Opinion, )
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For patients with reduced or deteriorating renal function following NU or other intervention, clinicians should consider referral to nephrology. (Expert Opinion, )
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Clinicians should 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 quality of life. (Expert Opinion, )
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Table 5. Surveillance after complete treatment

Having trouble viewing table?
Year 1 2 3 4 5
Month 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 60+
Kidney-Sparing, Low-Risk
Cystoscopy, Cytology - X X - X - X - X - - - X - - - X - - - X -
Upper Tract Endoscopy - X X - X - - - - - - - - - - - - - - - - -
Cross-Sectional Imaging* - X - - X - X - X - - - X - - - X - - - X -
Chest Imaging - - - - X - - - - - - - - - - - - - - - - -
BMP - - - - X - - - X - - - X - - - X - - - X -
Kidney-Sparing, High-Risk
Cystoscopy, Cytology - X X - X - X - X - X - X - - - X - - - X O
Upper Tract Endoscopy - X X - X - - - - - - - - - - - - - - - - -
Cross-Sectional Imaging* - X X - X - X - X - X - X - - - X - - - X O
Chest Imaging - - X - X - X - X - - - X - - - - - - - - -
BMP - - - - X - - - X - - - X - - - X - - - X -
Post Nephroureterectomy, <pT2, N0/NX
Cystoscopy, Cytology - X X O X - X - X - - - X - - - X - - - X -
Cross-Sectional Imaging* - - X - X - - - X - - - X - - - O - - - O -
Chest Imaging - - - - X - - - - - - - - - - - - - - -
BMP - X - - X - - - X - - - X - - - X - - - X -
Post Nephroureterectomy, ≥pT2
Cystoscopy, Cytology - X X - X - X - X - X - X - - - X - - - X O
Cross-Sectional Imaging* - X X - X - X - X - - - X - - - X - - - X O
Chest Imaging - X X - X - X - X - - - X - - - X - - - X -
BMP - X - - X - - - X - - - X - - - X - - - X -
X = Recommended (Should be performed in the associated time interval)
O = Optional (May be performed in the associated time interval)
- = As indicated (Performed in the associated time interval for clinical indications)

The following surveillance schedules are recommended in the setting of complete treatment where no residual or recurrent tumor is identified or clinically suspected. Earlier intervals of follow-up endoscopy may be used in cases of concern for incomplete treatment (eg, larger tumors, more difficult access, poor visibility, disease biology). The Panel recognizes the limitations of the data on tumor recurrence and optimal intervals of follow-up which require further study. Any clinical findings of new or worsening disease should prompt re-evaluation

Cross-sectional imaging of the abdomen and pelvis with CT or MRI should be performed with contrast when possible

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma

Authoring Organizations

Publication Month/Year

April 25, 2023

Last Updated Month/Year

December 20, 2023

Document Type

Guideline

Country of Publication

US

Document Objectives

The purpose of this guideline is to provide a useful reference on the effective evidence-based diagnoses and management of non-metastatic upper tract urothelial carcinoma (UTUC).

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Management

Diseases/Conditions (MeSH)

D014551 - Urinary Tract, D019459 - Urothelium, D002277 - Carcinoma

Keywords

Urothelial Cancer, UTUC, upper tract urothelial carcinoma, lymph node dissection

Source Citation

Coleman JA, Clark PE, Bixler BR, Buckley DI, Chang SS, Chou R, Hoffman-Censits J, Kulkarni GS, Matin SF, Pierorazio PM, Potretzke AM, Psutka SP, Raman JD, Smith AB, Smith L. Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline. J Urol. 2023 Apr 25:101097JU0000000000003480. doi: 10.1097/JU.0000000000003480. Epub ahead of print. PMID: 37096584.

Supplemental Methodology Resources

Data Supplement