Elsevier

European Urology

Volume 79, Issue 1, January 2021, Pages 62-79
European Urology

Platinum Priority – Review – Urothelial Cancer
Editorial by John D. Chester on pp. 80–81 of this issue.
European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update

https://doi.org/10.1016/j.eururo.2020.05.042Get rights and content

Abstract

Context

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

Objective

To provide an overview of the EAU guidelines on UTUC as an aid to clinicians.

Evidence acquisition

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts.

Evidence synthesis

Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC.

Conclusions

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

Patient summary

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.

Introduction

The previous European Association of Urology (EAU) Guidelines on Upper Urinary Tract Urothelial Carcinoma (UTUC) were published in 2017 [1]. The EAU Guidelines Panel has prepared updated guidelines to provide evidence-based information on the management of these tumours in clinical practice.

Section snippets

Data identification

Databases searched included PubMed, Ovid, EMBASE, and both the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. A detailed search history is available in the Supplementary material. The publications identified were mainly retrospective, including some large multicentre studies. Owing to the scarcity of randomised data, articles were selected based on the following criteria: evolution of concepts, intermediate- and long-term clinical outcomes, study

Epidemiology

Urothelial carcinomas (UCs) are the fourth most common tumours [3]. They can be located in the lower (bladder and urethra) or the upper (pyelocaliceal cavities and ureter) urinary tract. Bladder tumours account for 90–95% of UCs and are the most common urinary tract malignancy [4]. However, UTUCs are uncommon and account for only 5–10% of UCs [3], with an estimated annual incidence in Western countries of almost two cases per 100 000 inhabitants. Pyelocaliceal tumours are approximately twice as

Classification

The classification and morphology of UTUC and bladder carcinoma are similar [29]. It is possible to distinguish between noninvasive papillary tumours (papillary urothelial tumours of low malignant potential and low- and high-grade papillary UC) [30], flat lesions (carcinoma in situ [CIS]), and invasive carcinoma.

Tumour, node, metastasis staging

The tumour, node, metastasis (TNM) classification is shown in Table 2 [31]. The regional lymph nodes (LNs) are the hilar and retroperitoneal nodes, and for the mid and distal ureter,

Symptoms

The diagnosis of UTUC may be incidental or symptom related. The most common symptom is visible or nonvisible haematuria (70–80%) [34], [35]. Flank pain occurs in approximately 20% of cases [36], [37]. Systemic symptoms (including anorexia, weight loss, malaise, fatigue, fever, night sweats, or cough) associated with UTUC should prompt evaluation for metastases associated with a worse prognosis [36], [37].

Computed tomography urography

Computed tomography (CT) urography has the highest diagnostic accuracy of the available

Prognostic factors

UTUCs that invade the muscle wall usually have a very poor prognosis. The 5-yr–specific survival is <50% for pT2/pT3 and <10% for pT4 UTUC [66], [67], [68], [69]. The main prognostic factors are briefly listed in the text. Fig. 2 shows a more exhaustive list of those patients with the most increased risk.

Kidney-sparing surgery

Kidney-sparing surgery for low-risk UTUC reduces the morbidity associated with radical surgery (eg, loss of kidney function), without compromising oncological outcomes [132]. In low-risk cancers, it is the preferred approach as survival is similar to that after RNU [132]. This option should therefore be discussed in all low-risk cases, irrespective of the status of the contralateral kidney. In addition, it can also be considered in select patients with a serious renal insufficiency or having a

Follow-up

The risk of recurrence and death evolves during the follow-up period after surgery [209]. Stringent follow-up (section 8.1) is mandatory to detect metachronous bladder tumours (probability increases over time [210]), local recurrence, and distant metastases. Surveillance regimens are based on cystoscopy and urinary cytology for >5 yr [5], [6], [7], [131]. Bladder recurrence is not considered a distant recurrence. When kidney-sparing surgery is performed, the ipsilateral upper urinary tract

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