AUA: Upper Tract Urothelial Carcinoma (2023): Difference between revisions
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*'''Reasonable alternatives to RNU for well-selected patients''' | *'''Reasonable alternatives to RNU for well-selected patients''' | ||
*Principles | *Principles | ||
* | *#'''Patient counseling''' to describe techniques, potential requirements for urinary reconstruction and associated complications including the potential impact on postoperative bladder function. | ||
* | *#'''Preoperative endoscopic assessment''' to evaluate sites of involvement and proximal extent of disease. | ||
* | *#'''Preoperative assessment of bladder capacity''' and function in cases where more extensive reconstruction such as a Boari flap are anticipated to permit a tension free ureterovesical anastomosis or the use of bowel segments. | ||
* | *#'''Intraoperative pathologic assessment''' (i.e., frozen sections) of proximal and distal margins to ensure complete resection with negative margins. | ||
* | *#Reasonable attempts to '''avoid of spillage of urine''' into the surgical field. | ||
* | *#'''Watertight, tension free closure''' to facilitate functional healing and avoid urine leak (of urine potentially contaminated with malignant cells). | ||
*'''When performing NU or distal ureterectomy, the entire distal ureter including the intramural ureteral tunnel and ureteral orifice should be excised, and the urinary tract should be closed in a watertight fashion.''' | *'''When performing NU or distal ureterectomy, the entire distal ureter including the intramural ureteral tunnel and ureteral orifice should be excised, and the urinary tract should be closed in a watertight fashion.''' | ||
**The resultant hiatus in the bladder in the location of the excised ureteral orifice with or without the bladder cuff can be closed formally in a watertight fashion in one or more layers | **The resultant hiatus in the bladder in the location of the excised ureteral orifice with or without the bladder cuff can be closed formally in a watertight fashion in one or more layers | ||
***A formal BCE with watertight closure of the bladder cuff should be performed to | |||
***A formal BCE with watertight closure of the bladder cuff should be performed to | |||
***#Avoid urinary extravasation from the bladder | ***#Avoid urinary extravasation from the bladder | ||
***#Facilitate more rapid catheter removal | ***#Facilitate more rapid catheter removal | ||
***#Permit instillation of intravesical adjuvant chemotherapy in the perioperative setting | ***#Permit instillation of intravesical adjuvant chemotherapy in the perioperative setting | ||
* | ***Delayed closure by secondary intension in a decompressed bladder without formal bladder closure has also been described. | ||
==== Lymph node dissection ==== | ==== Lymph node dissection ==== | ||
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===== Adjuvant chemotherapy ===== | ===== Adjuvant chemotherapy ===== | ||
* Platinum-based adjuvant chemotherapy should be offered to patients with advanced pathological stage (pT2–T4 pN0–N3 M0 or pTany N1–3 M0) UTUC after RNU or ureterectomy who have not received neoadjuvant platinum-based therapy | * Adjuvant intravesical chemotherapy | ||
** Adjuvant platinum-based chemotherapy for select patients with UTUC post-RNU is a standard based on results from the randomized phase III POUT trial. | **'''In patients undergoing RNU or SU (including distal ureterectomy) for UTUC, a single dose of perioperative intravesical chemotherapy should be administered in eligible patients to reduce the risk of bladder recurrence.''' | ||
*** Subjects in the adjuvant chemotherapy arm had improved DFS and lower risk of metastases or death, compared with those on observation. | ***The exact timing of therapy has varied including instilling intravesical chemotherapy at the time of catheter removal (ODMIT-C trial), while other retrospective series reported instillation during surgery or up to 48 hours postoperatively. | ||
*** A subgroup analysis demonstrated that outcomes for patients with lymph node involvement and those treated with carboplatin chemotherapy were worse than those without positive nodes or treated with cisplatin chemotherapy | ***Little data to support one intravesical chemotherapeutic over another. | ||
*** Carboplatin remains a reasonable choice for HR cisplatin-ineligible patients post-RNU if NAC was not given | ****Many use gemcitabine over mitomycin due to risks of chemical peritonitis with extravesical extravasation of MMC | ||
*Adjuvant systemic chemotherapy | |||
**Platinum-based adjuvant chemotherapy should be offered to patients with advanced pathological stage (pT2–T4 pN0–N3 M0 or pTany N1–3 M0) UTUC after RNU or ureterectomy who have not received neoadjuvant platinum-based therapy | |||
*** Adjuvant platinum-based chemotherapy for select patients with UTUC post-RNU is a standard based on results from the randomized phase III POUT trial. | |||
**** Subjects in the adjuvant chemotherapy arm had improved DFS and lower risk of metastases or death, compared with those on observation. | |||
**** A subgroup analysis demonstrated that outcomes for patients with lymph node involvement and those treated with carboplatin chemotherapy were worse than those without positive nodes or treated with cisplatin chemotherapy | |||
**** Carboplatin remains a reasonable choice for HR cisplatin-ineligible patients post-RNU if NAC was not given | |||
===== Adjuvant immunotherapy ===== | ===== Adjuvant immunotherapy ===== | ||