WCE 2017: Endourologic Management of Upper Tract Urothelial Carcinoma

Vancouver, Canada (UroToday.com) Currently in press, the 2017 update to the European Association of Urology (EAU) guidelines on upper urinary tract urothelial carcinoma  (UTUC) utilizes risk stratification based on focality and grade of ureteroscopy/ureteroscopic (URS) biopsy. The guidelines recommend offering kidney-sparing management as primary treatment to patients with low-risk tumors and two functional kidneys. 

In order to evaluate the accuracy of URS in predicting the final pathological grade of upper tract lesions, Gupta’s group conducted a retrospective analysis of 81 patients status-post radical nephroureterectomy (RNU), all of whom had undergone an initial URS biopsy: see Yamany et al. (2015). URS biopsy predicted the correct grade in 64 cases (79%) with a sensitivity and specificity of 76% and 96%, respectively.

Gadzinski et al. (2010) found that only the grade of UTUC was associated with metastasis-free survival, cancer-specific survival (CSS), and overall survival on multivariate analysis; the type of treatment, RNU vs. endourologic management, was not associated with outcomes for survival. For low grade UTUC, five-year CSS was 100% for endourologic management vs. 89% for RNU. These numbers are much lower for high grade UTUC, i.e., 86% and 72% for endourologic management and for RNU, respectively. 

Endourologic management of UTUC can be done through either an URS or a percutaneous approach. URS resection offers the advantage of maintaining a closed system and should be utilized in small (less than 1 cm) lesions located in the ureter, renal pelvis, or upper calyces. Percutaneous resection is more invasive and should be utilized in larger (equal to or greater than 1 cm) lesions located in less accessible calyces or areas of the renal pelvis. 

The disadvantage of endourologic management of UTUC is life-long multimodal surveillance. Therefore, RNU should be offered early if endourologic management is likely to fail.

Presented by: Mantu Gupta, MD

Plenary Chair(s): Ali Kural, MD, Benjamin Lee, MD
Session Chair: Seiji Naito, MD

Affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA, Acibadem University, Department of Urology, Istanbul, Turkey, University of Arizona College of Medicine, Tucson, Arizona, Harasanshin Hospital Fukuoka, Japan

Written by: Michael Owyong (@ohyoungmike), LIFT Fellow, Department of Urology, UC Irvine Medical Center, Orange, CA, USA at 35th World Congress of Endourology– September 12-16, 2017, Vancouver, Canada.