Nephron-sparing management of upper tract urothelial carcinoma

Abstract

Urothelial carcinoma of the upper urinary tract is uncommon and presents unique challenges for diagnosis and management. Nephroureterectomy has been the preferred management option, but it is associated with significant morbidity. Nephron-sparing treatments are a valuable alternative and provide similar efficacy in select cases. A PubMed literature review was performed in English language publications using the following search terms: urothelial carcinoma, upper tract, nephron-sparing, intraluminal and systemic therapy. Contemporary papers published within the last 10 years were primarily included. Where encountered, systematic reviews and meta-analyses were given priority, as were randomized controlled trials for newer treatments. Core guidelines were referenced and citations reviewed for inclusion. A summary of epidemiological data, clinical diagnosis, staging, and treatments focusing on nephron-sparing approaches to upper tract urothelial carcinoma (UTUC) are outlined. Nephron-sparing management strategies are viable options to consider in patients with favorable features of UTUC. Adjunctive therapies are being investigated but the data remains mixed. Protocol variability and dosage differences limit statistical interpretation. New mechanisms to improve treatment dwell times in the upper tracts are being designed with promising preliminary results. Studies investigating systemic therapies are ongoing but implications for nephron-sparing management are uncertain. Nephron-sparing management is an acceptable treatment modality best suited for favorable disease. More work is needed to determine if intraluminal and/or systemic therapies can further optimize treatment outcomes beyond resection alone.

Successful Kidney-Sparing Systemic Therapy for a High-Risk Ureteral Carcinoma Case

“…As for low-risk UTUC cases or solitary kidney cases, kidney-sparing therapy such as ureteroscopic retrograde tumor ablation, percutaneous antegrade tumor ablation, and segmental ureterectomy may be a better choice [5]. However, to prevent postoperative recurrence, systemic therapy should be applied, though the investigation is still ongoing [6].…”

A prospective, single-arm trial of fluorescent ureteroscopy-assisted thulium-holmium:YAG dual laser ablation for upper urinary tract cancer: Study protocol of the FLUAM trial

“…Radical nephroureterectomy (RNU) with removal of distal ureter (bladder cuff excision) is the gold standard for localized UTUC [ [1] , [2] , [3] ], but is associated with a significant loss of renal function [ 4 , 5 ]. Thus, kidney-sparing management involves alternatives that do not compromise oncological outcomes in well-selected patients [ 2 , 6 , 7 ]. The latest European Association of Urology guidelines on UTUC lists three recommendations as follows [ 2 ]: offer kidney-sparing management as primary treatment option to patients with low-risk tumors (strongly recommended), offer kidney-sparing management (distal ureterectomy) to patients with high-risk tumors limited to the distal ureter (poorly recommended), and offer kidney-sparing management to patients with solitary kidney and/or impaired renal function, providing that it will not compromise survival (strongly recommended).…”

Organ-Preserving Surgery in Urethral Cancer (a Clinical Case)

“…Выбор метода зависит как от технических ограничений, так и от анатомического расположения опухоли и опыта хирурга. Среди органосохраняющих методов выделяют эндоскопическое удаление опухоли и сегментарную резекцию мочеточника [12,13]. Дистальная уретерэктомия с формированием уретероцистонеоанастомоза рекомендована для опухолей низкого риска, локализованных в дистальном отделе мочеточника, которые нельзя полностью удалить эндоскопически, и для опухолей высокого риска при необходимости органосохраняющего подхода для сохранения функции почек [14].…”