Editing AUA: Upper Tract Urothelial Carcinoma (2023) (section)

=== Patient counseling ===

* '''<span style="color:#ff0000">Discuss and facilitate smoking cessation, if applicable,</span> with patients at the time of diagnosis and treatment.''' 
**Risk factors such as smoking are associated with advanced disease stage, recurrence and worse cancer-specific mortality among patients with UTUC, with the highest risk among current smokers.
*'''<span style="color:#ff0000">Provide patients with a description of the short- and long-term risks associated with recommended diagnostic and therapeutic options, including</span>'''
**'''<span style="color:#ff0000">Need for endoscopic follow-up</span>'''
***Urothelial recurrences are common in the management of UTUC, regardless of approach, and mandate long-term surveillance for which patients must be prepared – including the potential need for additional treatments.
**'''<span style="color:#ff0000">Risks of treatment</span>'''
***'''<span style="color:#ff0000">Risk of clinically significant strictures with endoscopic management</span>''' 
****Ablative options can provide local control including durable long-term kidney sparing outcomes but incur additional endoscopic surveillance requirements and associated risks such as stricture and infection
****Use of chemoablative treatment with the reverse thermo-hydrogel preparation of mitomycin for pyelocaliceal instillation for LG tumors carries an FDA label warning for ureteral obstruction (>44%), bone marrow suppression, and embryo-fetal toxicity.
***'''<span style="color:#ff0000">Risk of post-nephroureterectomy CKD or dialysis</span>'''
****'''Risk factors for post-operative development of CKD or progression of pre-existing CKD (8):'''
****#'''Older age'''
****#'''Diabetes mellitus'''
****#'''Hypertension'''
****#'''Male sex'''
****#'''Obesity'''
****#'''Tobacco use'''
****#'''Larger tumor size'''
****#'''Post-operative acute kidney injury.'''
****'''Perioperative nephrology consultation can be considered, particularly in patients with pre-existing kidney disease.''' 
*****'''<span style="color:#ff0000">Indications for referral to nephrology (4):</span>'''
*****#'''<span style="color:#ff0000">eGFR < 45 mL/min/1.73m2</span>'''
*****#'''<span style="color:#ff0000">Confirmed proteinuria</span>'''
*****#'''<span style="color:#ff0000">Diabetics with preexisting CKD</span>'''
*****#'''<span style="color:#ff0000">If eGFR is expected to be < 30 mL/min/1.73m2 after intervention.</span>'''
**** In patients with pre-existing CKD or a solitary kidney, attempts to preserve renal function can be made, if oncologically feasible and appropriate, with segmental or endoscopic organ-sparing approaches which preferentially are associated with improved postoperative renal function.
****In patients with sufficiently poor CKD in which NU could precipitate ESRD, a post operative plan for dialysis in conjunction with nephrology colleagues should be in place preoperatively including plans for dialysis access. Referral to nephrology for detailed evaluation and recommendations for perioperative management is warranted in such cases
***'''<span style="color:#ff0000">Side effects from neoadjuvant and adjuvant therapies.</span>'''