AUA: Upper Tract Urothelial Carcinoma (2023): Difference between revisions

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 ***'''<span style="color:#ff0000">Side effects from neoadjuvant and adjuvant therapies.</span>'''
-=== Kidney Sparing Management ===
+=== Kidney Sparing Management/Tumor Ablation ===
-* '''Tumor ablation'''
+=== Indications ===
-** '''Indications'''
+* '''Preferred'''
-*** '''Preferred initial management for LR favorable UTUC, when technically feasible'''
+**'''Initial management for LR favorable UTUC, when technically feasible'''
-****Observational studies suggest similar cancer-specific survival, similar complication rates, and improved renal function outcomes with endoscopic ablation, compared to nephroureterectomy
+***Observational studies suggest similar cancer-specific survival, similar complication rates, and improved renal function outcomes with endoscopic ablation, compared to nephroureterectomy
-****'''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'''
+***'''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'''
-*****Risk of ureteric stenosis Instillation of mitomycin containing reverse thermal gel
+****High risk of ureteric stenosis with instillation of mitomycin containing reverse thermal gel
-*** '''Optional initial management for LR unfavorable UTUC and select patients with HR favorable disease who have low-volume tumors or cannot undergo RNU'''
+* '''Optional'''
-****For patients with LR unfavorable disease who demonstrate progression in tumor size, focality, or grade, the Panel recommends against further endoscopic-assisted attempts and consideration of definitive resection via segmental ureterectomy (SU) or NU.
+**'''Initial management for LR unfavorable UTUC and select patients with HR favorable disease who have low-volume tumors or cannot undergo RNU'''
-***'''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
+=== Technical considerations ===
-****'''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.'''
+* '''Approach'''
-** Approach
+**'''May be accomplished via a retrograde or antegrade percutaneous approach'''
-*** May be accomplished via a retrograde or antegrade percutaneous approach
+***Antegrade approach typically reserved for
-****Antegrade approach typically reserved for larger tumors, those that are difficult to access in a retrograde fashion, or in patients who have undergone prior radical cystectomy or urinary diversion
+****Larger tumors
-***Energy source
+****Tumor difficult to access in a retrograde fashion
-****Thulium laser, holmium laser, Neodymium (Nd:YAG), and electrocautery devices (e.g., Bugbee) may all be deployed through an endoscope.
+****Patients who have undergone prior radical cystectomy or urinary diversion
-***Chemoablation
+*'''Tumor size'''
-****may be employed either through retrograde ureteral catheter instillation or percutaneous access with fluoroscopic imaging guidance
+**'''Tumors < 1.5 cm in size may be optimal for endoscopic ablation given a lower risk of invasive disease.'''
-***Ureteral access sheath
+***Tumors ≥ 1.5 cm in size are associated with a > 80% risk of invasive disease
-****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
+***'''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.'''
-****Advantages
+*Energy source
-*****Allows for repeated scope passage up and down the ureter for sampling
+**Thulium laser, holmium laser, Neodymium (Nd:YAG), and electrocautery devices (e.g., Bugbee) may all be deployed through an endoscope.
-*****Means of fluid egress from the upper tract to avoid excess pelvicalyceal hydrostatic pressure from irrigation solutions
+*Chemoablation
-*****Observational study found that use associated with lower rate of intravesical recurrence
+**May be employed either through retrograde ureteral catheter instillation or percutaneous access with fluoroscopic imaging guidance
-** '''Adjuvant therapy'''
+*Ureteral access sheath
-*** '''Pelvicalyceal or intravesical chemotherapy'''
+**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
-****'''Considered an optional part of routine practice''' following ablation of UTUC tumors and after confirming there is no perforation of the bladder or upper tract
+**Advantages (3):
-****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
+**#Allows for repeated scope passage up and down the ureter for sampling
-****Approaches
+**#Means of fluid egress from the upper tract to avoid excess pelvicalyceal hydrostatic pressure from irrigation solutions
-*****Antegrade perfusion by nephrostomy tube
+**#Lower rate of intravesical recurrence (based on observational study)
-*****Retrograde perfusion via ureteral catheter,
+'''Adjuvant therapy'''
-*****Bladder instillation by transurethral catheter with reflux via a double J ureteral stent.
+* '''Pelvicalyceal or intravesical chemotherapy'''
-******In the third scenario, it is recommended to perform a cystogram and demonstrate adequate reflux of contrast into the pyelocaliceal system.
+**'''Considered an optional part of routine practice''' following ablation of UTUC tumors and after confirming there is no perforation of the bladder or upper tract
-****'''Pelvicalyceal BCG'''
+**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
-*****'''May be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS).'''
+**Approaches
-*****Consists of a 6-week induction course of BCG
+***Antegrade perfusion by nephrostomy tube
-*****'''Imperative indications'''
+***Retrograde perfusion via ureteral catheter,
-******'''Solitary kidney status'''
+***Bladder instillation by transurethral catheter with reflux via a double J ureteral stent.
-******'''Bilateral UTUC'''
+****In the third scenario, it is recommended to perform a cystogram and demonstrate adequate reflux of contrast into the pyelocaliceal system.
-******'''RIsk of progression to end-stage renal disease'''
+**'''Pelvicalyceal BCG'''
-**'''Repeat endoscopic evaluation'''
+***'''May be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS).'''
-***Proclivity of UTUC to recur and for residual disease to remain after the first ablation
+***Consists of a 6-week induction course of BCG
-***'''Should be performed within three months'''
+***'''Imperative indications'''
-****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
+****'''Solitary kidney status'''
-***'''Repeat endoscopic assessment should occur within three-month intervals until no evidence of upper tract disease is identified.'''
+****'''Bilateral UTUC'''
-**'''When tumor ablation is not feasible or evidence of risk group progression is identified in patients with LR UTUC, surgical resection of all involved sites either by RNU or segmental resection of the ureter should be offered.'''
+****'''RIsk of progression to end-stage renal disease'''
+'''Repeat endoscopic evaluation'''
+*Proclivity of UTUC to recur and for residual disease to remain after the first ablation
+*'''Should be performed within three months'''
+**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
+*'''Repeat endoscopic assessment should occur within three-month intervals until no evidence of upper tract disease is identified.'''
+*For patients with LR unfavorable disease who demonstrate progression in tumor size, focality, or grade, the Panel recommends against further endoscopic-assisted attempts and consideration of definitive resection via segmental ureterectomy (SU) or NU.
+'''When tumor ablation is not feasible or evidence of risk group progression is identified in patients with LR UTUC, surgical resection of all involved sites either by RNU or segmental resection of the ureter should be offered.'''
 === Surgical management ===