European Guidelines on Upper Tract Urothelial Carcinomas: 2013 Update

doi:10.1016/j.eururo.2013.03.032

European Urology

Volume 63, Issue 6, June 2013, Pages 1059-1071

https://doi.org/10.1016/j.eururo.2013.03.032 Get rights and content

Abstract

Context

The European Association of Urology (EAU) guideline group for upper tract urothelial carcinoma (UTUC) has prepared updated guidelines to aid clinicians in assessing the current evidence-based management of UTUC and to incorporate present recommendations into daily clinical practice.

Objective

To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians in their daily clinical practice.

Evidence acquisition

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified using a systematic search of Medline. Data on urothelial malignancies and UTUCs in the literature were searched using Medline with the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; nomogram; and survival. References were weighted by a panel of experts.

Evidence synthesis

There is a lack of data in the current literature to provide strong recommendations (ie, grade A) due to the rarity of the disease. A number of recent multicentre studies are now available, and there is a growing interest in UTUC in the recent literature. Overall, 135 references have been included here, but most of these studies are still retrospective analyses. The TNM 2009 classification is recommended. Recommendations are given for diagnosis as well as radical and conservative treatment (ie, imperative and elective cases); additionally, prognostic factors are discussed. Recommendations are also provided for patient follow-up after different therapeutic options.

Conclusions

These guidelines contain information for the management of individual patients according to a current standardised approach. Physicians must take into account the specific clinical characteristics of each individual patient when determining the optimal treatment regimen including tumour location, grade, and stage; renal function; molecular marker status; and medical comorbidities.

Introduction

The prior version of the European Association of Urology (EAU) guidelines on upper urinary tract tumours known as upper tract urothelial carcinomas (UTUCs) were published in 2011 [1]. The EAU Guidelines Working Panel for UTUCs has prepared the current guidelines to provide evidence-based information for the clinical management of these rare tumours and to help clinicians incorporate these recommendations into their practice. The current update is based on a structured literature search.

Section snippets

Data identification

A Medline search was performed on urothelial malignancies and UTUC management using combinations of the following terms: urinary tract cancer; urothelial carcinomas; upper urinary tract; carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; nomogram; and survival. The publications concerning UTUCs were mostly retrospective including some large multicentre studies. Due to the scarcity

Epidemiology

Urothelial carcinomas (UCs) are the fourth most common tumours after prostate (or breast), lung, and colorectal cancer [4], [5]. They can be located in the lower urinary tract (bladder and urethra) or upper urinary tract (pyelocaliceal cavities and ureter). Bladder tumours account for 90–95% of UCs and are the most common malignancy of the urinary tract [1], [5]. In contrast, UTUCs are uncommon and account for only 5–10% of UCs [4], [6]. The estimated annual incidence of UTUCs in Western

Conclusions

These renewed UTUC guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen for their patients, urologists must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidity; tumour location, grade, and stage; and molecular marker status.

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UGN-101 has been approved for the chemoablation of low-grade upper tract urothelial cancer (UTUC) involving the renal pelvis and calyces. Herein is the first reported cohort of patients with ureteral tumors treated with UGN-101.
We performed a retrospective review of patients treated with UGN-101 for UTUC at 15 high-volume academic and community centers focusing on outcomes of patients treated for ureteral disease. Patients received UGN-101 with either adjuvant or chemo-ablative intent. Response rates are reported for patients receiving chemo-ablative intent. Adverse outcomes were characterized with a focus on the rate of ureteral stenosis.
In a cohort of 132 patients and 136 renal units, 47 cases had tumor involvement of the ureter, with 12 cases of ureteral tumor only (8.8%) and 35 cases of ureteral plus renal pelvic tumors (25.7%). Of the 23 patients with ureteral involvement who received UGN-101 induction with chemo-ablative intent, the complete response was 47.8%, which did not differ significantly from outcomes in patients without ureteral involvement. Fourteen patients (37.8%) with ureteral tumors had significant ureteral stenosis at first post-treatment evaluation, however, when excluding those with pre-existing hydronephrosis or ureteral stenosis, only 5.4% of patients developed new clinically significant stenosis.
UGN-101 appears to be safe and may have similar efficacy in treating low-grade urothelial carcinoma of the ureter as compared to renal pelvic tumors.
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Retrograde pyelography (RP) is performed for examination of upper urinary tract cancers and hydronephrosis. Although urinary tract infections (UTI) are known to be complicated by the examination, there are few reports on the frequency of occurrence and prophylactic antibiotics.
The incidence of UTI and febrile UTI (f-UTI) and patient background information were compared in 388 patients who underwent RP at our hospital from January 2018 to December 2022. We also examined the administration of pre-RP antibiotics.
Of the 388 patients who underwent RP, 27 (6.9%) had UTI and 17 (4.4%) had f-UTI. Of the 27 UTI cases, 25 (92.6%) were pyelonephritis; 20 (74.0%) were hospitalized and 2 (7.4%) presented with septic shock and were managed in the intensive care unit. When comparing the background of patients with UTI, no significant differences were found in the present study, but when limited to the 17 cases of f-UTI, the presence of hydronephrosis before RP and not prescribing antibiotics before RP were associated with significantly higher incidence of f-UTI (p = 0.019, p = 0.036, respectively). Especially for patients without pyuria and bacteriuria before RP, prescribing antibiotics before RP resulted in 0 cases of f-UTI (p = 0.020).
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GuidelinesEuropean Guidelines on Upper Tract Urothelial Carcinomas: 2013 Update

Abstract

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Introduction

Section snippets

Data identification

Epidemiology

Conclusions

Eur Urol

Eur Urol

J Urol

Eur Urol

Eur Urol

Eur Urol

Urology

Eur Urol

Lancet

J Urol

Mod Pathol

Urology

Urology

Cancer Treat Rev

J Urol

Eur Urol

Urol Oncol

J Urol

J Urol

J Urol

J Urol

Eur Urol

Clin Radiol

J Urol

Urology

J Urol

J Urol

Urology

Urology

Eur Urol

Eur Urol

Eur Urol

J Urol

Urology

J Urol

Eur Urol

Eur Urol

Eur Urol

Eur Urol

Eur Urol

J Urol

Urol Oncol

Urol Oncol

Urology

J Urol

J Urol

The present and future burden of urinary bladder cancer in the world

World J Urol

Cancer statistics, 2012

CA Cancer J Clin

Upper urinary tract urothelial cell carcinoma: location as a predictive factor for concomitant bladder carcinoma

World J Urol

Guidelines
European Guidelines on Upper Tract Urothelial Carcinomas: 2013 Update