Optimal management of upper tract urothelial carcinoma : current perspectives

Abstract

Introduction: Upper tract urothelial carcinoma (UTUC) is a relatively uncommon urologic malignancy for which there has not been significant improvement in survival over the past few decades, highlighting the need for optimal multi-modality management. Methods: A non-systematic review of the latest literature was performed to include relevantarticles up to June 2019. It summarizes the epidemiologic risk factors associated with UTUC,including smoking, carcinogenic aromatic amines, arsenic, aristolochic acid, and Lynchsyndrome. Molecular pathways underlying UTUC and potential druggable targets are outlined. Results: Surgical management for UTUC includes kidney-sparing surgery (KSS) for low-risk disease and radical nephroureterectomy (RNU) for high-risk disease. Endoscopic man-agement of UTUC may include ureteroscopic or percutaneous resection. Topical instillationtherapy post-KSS aims to reduce recurrence, progression and to treat carcinoma-in-situ; thismay be achieved retrogradely (via ureteric catheterization), antegradely (via percutaneousnephrostomy) or via reflux through double-J stent. RNU, which may be performed via open,laparoscopic or robot-assisted approaches, is the gold standard treatment for high-riskUTUC. The distal cuff may be dealt with extravesical, transvesical or endoscopic techniques.Peri-operative chemotherapy and immunotherapy are increasingly utilized; level 1 evidenceexists for adjuvant chemotherapy, but neoadjuvant chemotherapy is favored as kidneyfunction is better prior to RNU. Immunotherapy is primarily reserved for metastatic UTUCbut is currently being investigated in the perioperative setting. Conclusion: The optimal management of UTUC includes afirm understanding of theepidemiological factors and molecular pathways. Surgical management includes KSS forlow-risk disease and RNU for high-risk disease. Peri-operative immunotherapy and che-motherapy may be considered as evidence mounts.