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  • Review Article
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Risk-adapted strategy for the kidney-sparing management of upper tract tumours

Nature Reviews Urology volume 12, pages 155–166 (2015)Cite this article

Subjects

Key Points

  • Use of a risk-adapted approach to select patients who are more likely to benefit from conservative, kidney-sparing surgery without compromising oncological safety has been advocated

  • Kidney-sparing surgery for the treatment of low-risk upper tract urothelial carcinoma in selected patients achieves similar oncological outcomes as radical nephroureterectomy

  • Growing evidence exists that a systematic endoscopic second-look after ureteroscopic and percutaneous management of upper tract urothelial carcinoma decreases the risk of local recurrence and progression

  • Adjuvant endocavitary instillations of topical agents might decrease the risk of local recurrence and progression after the endoscopic management of patients with upper tract urothelial carcinoma

  • A single, early intravesical instillation of mitomycin C after kidney-sparing surgery for upper tract urothelial carcinoma might decrease the risk of recurrence in the bladder

  • Meticulous and stringent endoscopic monitoring of the upper and lower urinary tract for recurrence is a key component of the conservative management of patients with upper tract urothelial carcinoma

Abstract

The conservative management of upper tract urothelial carcinoma (UTUC) was traditionally restricted to patients with imperative indications only. However, current recommendations suggest selected patients with normal, functioning contralateral kidneys should also be considered for such an approach. A risk-adapted strategy to accurately select patients who could benefit from kidney-sparing surgery without compromising their oncological safety has been advocated. A number of kidney-sparing surgical procedures are available. Despite the advent of ureteroscopic management, segmental ureterectomy and the percutaneous approach both have specific indications for use that predominantly depend on the tumour location and progression risk. These kidney-sparing procedures are cost-effective, and when used to treat patients with low-risk UTUC, are associated with oncological outcomes similar to radical nephroureterectomy. Systematic second-look endoscopy combined with upper tract instillations of topical chemotherapeutic agents after ureteroscopic or percutaneous surgery and a single early intravesical instillation of mitomycin C after any kidney-sparing procedure might decrease the risks of local recurrence and progression. Meticulous and stringent endoscopic monitoring of the upper and lower urinary tract is a key component of the conservative management of UTUC. Local recurrences are often suitable for repeat conservative therapy, whereas disease progression should be treated with delayed radical nephroureterectomy.

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Figure 1: Suggested algorithm for the risk-adapted selection of conservative management strategies or radical nephroureterectomy in patients with UTUCs.
Figure 2: Suggested algorithm for selection of the optimal risk-adapted approach for kidney-sparing surgical treatment of UTUC in the presence of elective or imperative indications.
Figure 3: Suggested algorithm for the adjuvant management of patients with UTUC after kidney-sparing surgery.

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  1. Academic Department of Urology, Hôpital de la Pitié-Salpétrière, Assistance Publique Hôpitaux de Paris, 47–83 Boulevard de l'Hôpital, Paris, F-75013, France

    Thomas Seisen & Morgan Rouprêt

  2. Department of Urology, Hôpital Privé de La Louvière, Générale de Santé, 69 rue de la Louvière, Lille, F-59042, France

    Pierre Colin

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  1. Thomas Seisen
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  2. Pierre Colin
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  3. Morgan Rouprêt
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Contributions

P.C. and M.R. made substantial contributions to the discussion of content, T.S. researched the data and wrote the article, P.C. and M.R. reviewed and/or edited the manuscript before submission.

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Correspondence to Morgan Rouprêt.

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The authors declare no competing financial interests.

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Seisen, T., Colin, P. & Rouprêt, M. Risk-adapted strategy for the kidney-sparing management of upper tract tumours. Nat Rev Urol 12, 155–166 (2015). https://doi.org/10.1038/nrurol.2015.24

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