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

=== Kidney Sparing Management/Tumor Ablation ===

==== Indications ====
* '''<span style="color:#ff0000">Preferred</span>''' 
**'''<span style="color:#ff0000">Initial management for LR favorable UTUC, when technically feasible</span>'''
***Observational studies suggest similar cancer-specific survival, similar complication rates, and improved renal function outcomes with endoscopic ablation, compared to nephroureterectomy
* '''<span style="color:#ff0000">Optional</span>''' 
**'''<span style="color:#ff0000">Initial management for LR unfavorable UTUC and select patients with HR favorable disease who have low-volume tumors or cannot undergo RNU</span>'''
*'''<span style="color:#ff0000">If low-risk and complete endoscopic ablation not feasible, chemoablation (in-situ tissue destruction) with mitomycin containing reverse thermal gel can be a treatment alternative</span>'''
**High risk of ureteric stenosis with instillation of mitomycin containing reverse thermal gel

==== Technical considerations ====
* '''Approach'''
**'''May be accomplished via a retrograde or antegrade percutaneous approach'''
***Antegrade approach typically reserved for
****Larger tumors 
****Tumor difficult to access in a retrograde fashion 
****Patients who have undergone prior radical cystectomy or urinary diversion 
*'''Tumor size'''
**'''Tumors < 1.5 cm in size may be optimal for endoscopic ablation given a lower risk of invasive disease.'''
***Tumors ≥ 1.5 cm in size are associated with a > 80% risk of invasive disease
***'''Larger tumors (≥ 1.5 cm) may be considered for ablation based on the provider’s experience and assessment of the need for kidney sparing surgery.'''
*Energy source
**Thulium laser, holmium laser, Neodymium (Nd:YAG), and electrocautery devices (e.g., Bugbee) may all be deployed through an endoscope.
*Chemoablation 
**May be employed either through retrograde ureteral catheter instillation or percutaneous access with fluoroscopic imaging guidance
*Ureteral access sheath
**Prior to placement of any ureteral access sheath, the entire ureter should be directly visualized in order to avoid missing any luminal neoplasms, especially in the distal ureter
**Advantages (3):
**#Allows for repeated scope passage up and down the ureter for sampling
**#Means of fluid egress from the upper tract to avoid excess pelvicalyceal hydrostatic pressure from irrigation solutions
**#Lower rate of intravesical recurrence (based on observational study)

==== Adjuvant therapy ====

===== Pelvicalyceal or intravesical chemotherapy following ablation of UTUC tumors =====
*'''Considered optional''' 
*Principle of an immediate instillation of intravesical or pyelocaliceal (upper tract) chemotherapy at the time of endoscopic tumor ablation for UTUC is undertaken by extrapolation of the data supporting immediate instillation of intravesical chemotherapy at the time of transurethral resection of a bladder tumor
*Prior to administration, must confirm that there is no perforation of the bladder or upper tract
*Approaches
*#Antegrade perfusion by nephrostomy tube
*#Retrograde perfusion via ureteral catheter
*#Bladder instillation by transurethral catheter with reflux via a double J ureteral stent. 
*#*In the third scenario, a cystogram and demonstration of adequate reflux of contrast into the pyelocaliceal system is recommended.

===== Pelvicalyceal BCG =====
*'''May be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS).'''
*Consists of a 6-week induction course of BCG
*'''Imperative indications'''
*#'''Solitary kidney status'''
*#'''Bilateral UTUC'''
*#'''RIsk of progression to end-stage renal disease'''

==== Repeat endoscopic evaluation ====
*'''<span style="color:#ff0000">Should be performed within 3 months</span>'''
**Proclivity of UTUC to recur and for residual disease to remain after the first ablation
**A 30-day window on either side of this endpoint (i.e., 30 to 90 days) is justified to allow timely identification of recurrences and may be dictated by aspects such as tumor size, visualization, access, treatment efficacy, etc., as clinically indicated
**'''<span style="color:#ff0000">If residual disease identified, repeat endoscopic assessment should occur within 3-month intervals until no evidence of upper tract disease is identified.</span>'''
* '''In patients with LR UTUC with evidence of risk group progression (tumor size, focality, or grade) or when tumor ablation is not feasible,''' further endoscopic-assisted attempts are not recommended. '''surgical resection of all involved sites either by RNU or segmental resection of the ureter should be offered.'''