Surgical management

The goals of management are a balance between:

• Oncological control
• Preservation of renal function
• Morbidity of treatment

 

Options for management include:

1. Nephroureterectomy
   1. Open vs lap vs robot
   2. Open distal end vs pluck
   3. Intravesical vs extravesical bladder cuff
2. Segmental ureterectomy
3. Endoscopic management
   1. Ureteroscopic / retrograde
   2. Percutaneous / antegrade
4. Upper tract topical treatment
5. Nephrectomy

 

Nephroureterectomy with excision of a cuff of bladder is the gold standard treatment for upper tract urothelial cancer.

EAU guidelines for low risk:

• Offer kidney sparing management as primary treatment to low risk tumours
• Offer distal ureterectomy to patients with high risk tumours limited to distal ureter
• Offer kidney sparing management to patients with solitary kidney or impaired renal function provided it will not compromise survival, on a case-by-case basis

 

EAU guidelines for high risk:

• Radical neph-u for high risk non metastatic UTUC
• Open neph-u if cT3 or cN+
• Perform template lymphadenectomy
• Offer post-operative platinum based chemotherapy to high risk non metastatic
• Deliver post-op intravesical chemo to reduce bladder recurrence rate