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

==== Surveillance after radical nephroureterectomy ====

* Intravesical recurrence
**Rates of intravesical recurrence after nephroureterectomy: ≈29%
*** Most recurrences occur within the first 2 years
**** Unclear how long bladder surveillance should continue for after 2 years
**Risk factors for intravesical recurrence:
**#Male sex
**#Previous bladder cancer
**#Preoperative CKD
**#Positive preoperative urinary cytology
**#Ureteral tumor size
**#Multifocality
**#Invasive pathologic T-stage
**#Presence of necrosis
**#Laparoscopic approach
**#Extravesical bladder cuff removal
**#Positive surgical margins
**#Prior ureteroscopic biopsy
**Given the substantial risk of local (bladder) recurrences within the first years following nephroureterectomy, risk adapted surveillance with cystoscopy and urine cytology at routine intervals is indicated to facilitate prompt detection of bladder recurrences.
* Contralateral recurrence
**Risk of recurrence to the contralateral upper tract: ≈2%
*Locoregional, retroperitoneal, and distant metastases
**Risk factors
***Multifocality
***Stage T3-4
***Grade G3
***Presence of lymph node metastasis
**Intrabdominal recurrences
***Very low rates in low-risk patients
***In patients with HG disease, LVI, or tumor multifocality, periodic imaging of the abdomen and pelvis is warranted, particularly for the first 2 years
**Distant metastases
***Lung metastasis
****Low risk in patients with <pT2 N0/M0
****Can occur in patients with high-grade disease, so periodic chest imaging is warranted
*****Chest imaging can be done via chest x-ray or CT
******Chest x-ray is likely sufficient, less costly, and associated with less radiation exposure
***Bone
***Liver
***Brain
****Rare following nephroureterectomy
****Patients undergoing follow-up for HR UTUC following nephroureterectomy with acute neurological signs or symptoms should undergo prompt neurologic evaluation with cross-sectional imaging of the brain and/or spine by CT or MRI

* '''<pT2 N0/M0 managed with NU'''
** Cystoscopy and urine cytology within 3 months after surgery, then repeated based on pathologic grade. 
***For LG this should repeated at least every 5-9 months for the first 2 years and then at least annually thereafter.
***For HG, this should be repeated at least every 3-6 months for the first 3 years and then at least annually thereafter.
**Cross-sectional imaging of the abdomen and pelvis should be done within 6 months after surgery and then at least annually for a minimum of 5 years
***Due to the metastasis risk and estimated 5% probability for contralateral disease
***Follow up after nephroureterectomy for patients with non-muscle invasive, node-negative UTUC should be largely focused on the risk of intravesical recurrence
**Surveillance after five years in the absence of recurrence should be encouraged and based on shared decision-making between the patient and clinician
* '''T2+ managed with NU'''
** Cystoscopy with cytology at 3 months after surgery, then every 3-6 months for 3 years, and then annually thereafter.
**Cross-sectional imaging of the abdomen and pelvis with multiphasic contrast-enhanced CT urography should be performed every 3-6 months for years 1 and 2, every 6 months at year 3, and annually thereafter to year 5.
**Chest imaging, preferably with chest CT, every 6-12 months for the first 5 years. 
**Beyond five years after surgery in patients without recurrence, ongoing surveillance with cystoscopy and upper tract imaging may be continued on an annual basis according to principles of shared/informed decision-making
*'''Sequelae of nephroureterectomy'''
**'''Repeat assessment of blood pressure, eGFR, and proteinuria should be performed soon after nephroureterectomy then again in 3-6 months to assess for development or progression of CKD.''' 
***With significant nephron mass loss, hyperfiltration can occur resulting in glomerular damage, exacerbation of proteinuria and progressive sclerosis with further decline in GFR.
***The long-term impact of renal dysfunction increases risks of osteoporosis, anemia, metabolic and cardiovascular disease, hospitalization and death.
***Effective treatment strategies are available to slow the progression of CKD and reduce cardiovascular risks, and therefore timely identification of progressive renal dysfunction and/or proteinuria can provide opportunity for medical intervention when indicated.
****Careful management of DM and HTN and avoidance of substantial weight gain may slow or prevent CKD progression and should be prioritized on a long-term basis
****Identifying modifiable risk factors including diabetes mellitus (DM), hypertension (HTN) and smoking is essential. Optimizing glycemic and blood pressure control, smoking cessation and minimizing risk of acute kidney injury (with avoidance of hypotension and nephrotoxic agents such as intravenous contrast or non-steroidal anti-inflammatory drugs) should reduce the degree of renal dysfunction in the perioperative period.
***'''In patients who develop progressive renal insufficiency or proteinuria should be referred to nephrology.'''
**Other laboratory evaluations (e.g., CBC, LDH, liver function tests, and alkaline phosphatase) may be obtained at the discretion of the clinician or if advanced disease is suspected.