Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma

Abstract

Introduction: The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group.

Methods: The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report.

Results: There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy.

Conclusions: Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC.

Keywords: Calyces; Nephroureterectomy; Renal pelvis; Upper tract; Ureteroscopy; Urothelial cancer.

Figure 1

Sagittal view of a computed tomography scan showing a filling defect representing a soft tissue mass in the upper pole of the left collecting system, in a patient with prior endoscopic therapy for low grade left ureteral tumors. Biopsy in this case showed high grade papillary tumor. Nephroureterectomy showed parenchymal invasion (stage pT3).

Figure 2

Photographs showing biopsy tools and potential specimen sizes. A) cup biopsy forceps and coaxial 3-way prong; B) steel-wire basket.

Figure 2

Photographs showing biopsy tools and potential specimen sizes. A) cup biopsy forceps and coaxial 3-way prong; B) steel-wire basket.

Figure 3

Figures showing our institutional technique for reliably instilling topical therapy to the upper tract by either nephrostomy tube or cystoscopically placed Beacon tip ureteral catheter. Patients are given the option of technique employed in the absence of data for the better technique.

Figure 4

Photomicrograph showing upper tract carcinoma in-situ. Original magnification 200x.

Figure 5

A partial nephrectomy specimen performed in a patient with a solitary kidney and polar tumor (T). Blue ink indicates the urothelial margin. As opposed to partial nephrectomy for parenchymal tumors, the urothelial margin needs to be planned and examined in addition when performing a partial nephrectomy for UTUC. Indications for partial nephrectomy are very narrow, and include an endoscopically unmanageable tumor, no multifocality, polar location, and imperative indications for kidney preservation.