EAU 2022: Implementing the Follow-up Schedule After Radical Nephroureterectomy for Low Risk Upper Tract Urothelial Carcinoma

(UroToday.com) The 2022 EAU annual meeting featured a session on new insights in the management of upper tract urothelial cancer, including a presentation by Dr. Alberto Martini discussing implementing the follow-up schedule after radical nephroureterectomy for low risk upper tract urothelial carcinoma. The current EAU follow-up guidelines for surgically-treated low risk upper tract urothelial carcinoma entails cystoscopies at 3 and 9 months and yearly thereafter till the 5th year. On the premise that the risk of recurrence in the contralateral kidney is non-negligible and no recommendation is provided by the current EAU guidelines on performing imaging or ureteroscopy during follow-up, the study aimed to provide data-driven recommendation to evaluate whether the current EAU follow-up scheme for low risk upper tract urothelial carcinoma should be implemented.


This study identified 204 patients with low risk upper tract urothelial carcinoma treated with radical nephroureterectomy from a multi-institutional database. Patients were followed up in compliance with the EAU guidelines and recurrences in the contralateral kidney or ureter were investigated in case of symptoms or hematuria through imaging and/or ureterorenoscopy. The crude risk of recurrence was evaluated against time from radical nephroureterectomy with the Locally Weighted Scatterplot Smoothing. Additionally, patients were stratified based on their prior history of urothelial carcinoma.

The median follow-up for survivors was 39 months, of which 151 (74%) of patients were male. A total of 138 (68%) patients had pTis/a and 66 (32%) patients had pT1 disease. Overall, there were 55 bladder recurrences and 17 in the contralateral kidney. The following figure displays the risk of bladder recurrence, with vertical lines corresponding to the time points when cystoscopies should be performed:

 

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At 5-years, time point after which cystoscopies should be interrupted, the risk of bladder recurrence was slightly less than 20% and kept decreasing. The following figure displays the risk of recurrence in the contralateral kidney or ureter. At 1-year the risk of recurrence was approximately 10%:

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Dr. Martini concluded his presentation by discussing implementing the follow-up schedule after radical nephroureterectomy for low risk upper tract urothelial carcinoma with the following take-home messages: 

  • The surveillance pattern, in terms of cystoscopies, for the detection of bladder recurrence after radical nephroureterectomy mirrors the one for low risk non-muscle-invasive bladder cancer
  • We found that this scheme should not be applied to low risk upper tract urothelial carcinoma since a high risk of bladder recurrence persists even after 5 years and urologists should counsel patients on undergoing cystoscopy beyond this time point
  • Additionally, one should obtain imaging or perform ureterorenoscopy 12 months after radical nephroureterectomy as part of the surveillance scheme for the timely detection of contralateral kidney recurrence

Presented by: Alberto Martini, MD, Vita-Salute San Raffaele, Milan, Italy

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2022 European Association of Urology (EAU) Annual Hybrid Meeting, Amsterdam, NL, Fri, July 1 – Mon, July 4, 2022.

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