Narrative review of the surgical management of high-risk upper tract urothelial carcinoma

Abstract

Upper tract urothelial carcinoma (UTUC) consist of malignancies arising from the urothelium of the collecting system including the renal calyces, renal pelvis down to the level of the distal ureter. High-risk disease consists of any of the following characteristics including (I) the presence of hydronephrosis, (II) tumor size greater than 2 cm, (III) high-grade cytology, (IV) high-grade pathological biopsy, (V) multifocal disease, (VI) previous radical cystectomy for bladder cancer, and (VII) variant histology. The standard surgical management for high-risk disease is radical nephroureterectomy (RNU) with regional lymph node dissection (LND) and bladder cuff excision. This treatment may be performed via an open, laparoscopic, or robotic-assisted laparoscopic approach with varying levels of potential morbidity. Regional LND plays an important prognostic role at the time of RNU in terms of improving staging accuracy for possible early adjuvant therapy. A single instillation of intravesical chemotherapy post-RNU can also help reduce bladder tumor recurrences in the postoperative period regardless of surgical technique. Neoadjuvant or adjuvant chemotherapy can further enhance oncological outcomes with this disease although there is a push toward neoadjuvant therapy due to loss of a renal unit and reduced renal function precluding some patients from adjuvant therapy. Further clinical trials are needed to examine the effects of immunotherapy in the multi-disciplinary treatment of this disease. In the review, we summarize the various surgical treatment options available for high-risk UTUC.