Contemporary Management and Trends in the Treatment of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75%, with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers. However, endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. A critical review of the current literature and various guidelines regarding tumor management in UTUC was undertaken, with a focus on surgical options. Topics reviewed include percutaneous and endoscopic approaches, laparoscopic nephroureterectomy (LNU), options regarding the management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in the treatment of UTUC. Both National Comprehensive Cancer Network (NCCN) and European Association of Urology (EAU) current guidelines are reviewed. Limited recommendations are provided by the American Urological Association (AUA). Scant level 1 or grade A evidence was noted in the establishment of the various guidelines. There is debate regarding how to best manage UTUC. With the current trend towards minimally invasive, localized, and precise surgical treatments for all solid malignancies, we must evaluate this movement as it applies to UTUC. Nephron sparing surgery is the preferred option, when feasible, in the management of other renal malignancies. This, too, must be considered when managing UTUC. Higher quality research is needed to better establish evidence-based guidelines. However, this is a challenging prospect given the low incidence of UTUC and the difficulties encountered in creating appropriate protocols. World J Nephrol Urol. 2015;4(2):189-200 doi: http://dx.doi.org/10.14740/wjnu200w