AUA Releases Clinical Practice Guideline for Nonmetastatic Upper Tract Urothelial Carcinoma

Jonathan Coleman, MD

The American Urological Association and Society of Urologic Oncology (SUO) have released a clinical practice guideline for the diagnosis and management of patients with nonmetastatic upper tract urothelial carcinoma.^1,2

Although upper tract urothelial carcinoma is a rare malignancy, upper tract urothelial carcinoma of the renal pelvis is associated with a 5-year mortality rate of 50% compared with less than 25% for bladder cancer.

“Upper tract urothelial carcinoma requires a specialized approach, and there is a need for updated strategies to help this vulnerable patient population,” Jonathan Coleman, MD, chair of the guideline panel and surgeon at Memorial Sloan Kettering Cancer Center, stated in a news release. “New information and guidelines like these can help improve cancer control and survival. Clinicians will not only learn how to evaluate patients, but they will get the most up to date information on treatment, surveillance, survivorship and more.”

The guideline includes recommendations on diagnosis and evaluation; risk stratification; kidney-sparing management; surgical management; lymph node dissection; neoadjuvant and adjuvant chemotherapy and immunotherapy; post-treatment surveillance; and survivorship.

To construct the guideline, a team from the Pacific Northwest Evidence-based Practice Center of Oregon Health & Science University utilized Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews to gather evidence, which was assigned strength ratings of high, moderate, or low to support strong, moderate, or conditional recommendations.²

Regarding diagnosis and evaluation, it is strongly recommended that a cystoscopy and cross- sectional imaging of the upper tract be performed for patients with suspected upper tract urothelial carcinoma. These patients should also be evaluated with diagnostic ureteroscopy and biopsy of any identified lesion and cytologic washing from the upper tract system being inspected. Additionally, histologic testing should be performed to identify patients with high probability of Lynch-related cancers who should be referred for genetic counseling and germline testing.

In terms of risk stratification, is strongly recommended that standardized assessment documenting clinically meaningful endoscopic and radiographic features should be performed to evaluate clinical staging and risk assessment. Subsequently, patients should be stratified by risk of invasive disease based on the endoscopic, cytologic, pathologic, and radiographic information collected. Last, they should undergo further stratification based on standard identified features into favorable- and unfavorable-risk groups.

Regarding treatment, tumor ablation is also strongly recommended as initial management for those with low-risk, favorable upper tract urothelial carcinoma. For patients with high-risk upper tract upper tract urothelial carcinoma, radical nephroureterectomy and segmental ureterectomy are strongly recommended.

For patients who undergo nephroureterectomy or distal ureterectomy, the entire distal ureter, including the intramural ureteral tunnel and ureteral orifice, should be excised. Additionally, the urinary tract should be closed in a watertight fashion. Furthermore, a single dose of perioperative intravesical chemotherapy should be given to eligible patients undergoing radical nephroureterectomy or segmental ureterectomy, including distal ureterectomy, to reduce the risk of bladder recurrence. It is strongly recommended that patients with high-risk upper tract urothelial carcinoma undergo lymph node dissection at the time of nephroureterectomy or ureterectomy.

Cisplatin-based neoadjuvant chemotherapy should be offered to high-risk patients undergoing radical nephroureterectomy or ureterectomy. Moreover, it is strongly recommended that platinum-based adjuvant chemotherapy be offered to patients with advanced pathological stage disease (pT2–T4 pN0–N3 M0 or pTany N1–3 M0) following radical nephroureterectomy or ureterectomy if they did not receive neoadjuvant platinum-based chemotherapy.

“SUO has been honored to work alongside the AUA to help develop numerous guidelines in urology,” Jeffrey Holzbeierlein, MD, president of SUO and vice president and physician in chief at the University of Kansas Cancer Center, stated in a news release. “We believe it’s important to take difficult diagnosis like non-metastatic UTUC and disseminate the most up-to-date information possible.”

References

1. American Urological Association releases non-metastatic upper tract urothelial carcinoma guideline. News release. American Urological Association. April 25, 2023. Accessed April 27, 2023. https://auanet.mediaroom.com/2023-04-25
2. Coleman JA, Clark PE, Bixler BR, et al. Diagnosis and management of non-metastatic upper tract urothelial carcinoma: AUA/SUO guideline. J Urol. Published online April 25, 2023. doi:10.1097/JU.0000000000003480