Georgios Gakis1, Tina Schubert2, Mehrdad Alemozaffar3, Joaquim Bellmunt4, Bernard H Bochner5, Steven A Boorjian6, Siamak Daneshmand3, William C Huang7, Tsunenori Kondo8, Badrinath R Konety9, Maria Pilar Laguna10, Surena F Matin11, Arlene O Siefker-Radtke12, Shahrokh F Shariat13, Arnulf Stenzl2. 1. Department of Urology, University Hospital Tübingen, Hoppe-Seyler Street 3, 72076, Tübingen, Germany. georgios.gakis@web.de. 2. Department of Urology, University Hospital Tübingen, Hoppe-Seyler Street 3, 72076, Tübingen, Germany. 3. USC/Norris Comprehensive Cancer Center, Institute of Urology, Los Angeles, CA, USA. 4. Dana-Farber Cancer Institute, Boston, MA, USA. 5. Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 6. Department of Urology, Mayo Clinic, Rochester, MN, USA. 7. Department of Urology, New York University Langone Medical Center, New York, NY, USA. 8. Department of Urology, Tokyo Women's Medical University, Tokyo, Japan. 9. Department of Urology, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA. 10. Department of Urology, AMC, University of Amsterdam, Amsterdam, The Netherlands. 11. Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA. 12. Department of Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA. 13. Department of Urology, Medical University Vienna, Vienna, Austria.
Abstract
PURPOSE: To provide a comprehensive overview and update of the joint consultation of the International Consultation on Urological Diseases (ICUD) and Société Internationale d'Urologie for the treatment of localized high-risk upper tract urothelial carcinoma (UTUC). METHODS: A detailed analysis of the literature was conducted reporting on treatment modalities and outcomes in localized high-risk UTUC. An international, multidisciplinary expert committee evaluated and graded the data according to the Oxford System of Evidence-based Medicine modified by the ICUD. RESULTS: Radical nephroureterectomy (RNU) is the standard of treatment for high-grade or clinically infiltrating UTUC and includes the removal of the entire kidney, ureter and ipsilateral bladder cuff. The distal ureter can be managed either by extravesical or transvesical approach, whereas endoscopically assisted procedures are associated with decreased intravesical recurrence-free survival. Post-operative intravesical chemotherapy decreases the risk of subsequent bladder tumour recurrence. Regional lymph node dissection is of prognostic importance in infiltrative UTUC, but its extent has not been standardized. Renal-sparing surgery is an option for manageable, high-grade tumours of any part of the upper tract, especially of the distal ureter, as an alternative to RNU. Endoscopy-based renal-sparing procedures are associated with a higher risk of recurrence and progression. CONCLUSIONS: A multimodal approach should be considered in localized high-risk UTUC to improve outcomes. RNU is the standard of treatment in high-risk disease. Renal-sparing approaches may be oncologically equivalent alternatives to RNU in well-selected patients, especially in those with distal ureteric tumours.
PURPOSE: To provide a comprehensive overview and update of the joint consultation of the International Consultation on Urological Diseases (ICUD) and Société Internationale d'Urologie for the treatment of localized high-risk upper tract urothelial carcinoma (UTUC). METHODS: A detailed analysis of the literature was conducted reporting on treatment modalities and outcomes in localized high-risk UTUC. An international, multidisciplinary expert committee evaluated and graded the data according to the Oxford System of Evidence-based Medicine modified by the ICUD. RESULTS: Radical nephroureterectomy (RNU) is the standard of treatment for high-grade or clinically infiltrating UTUC and includes the removal of the entire kidney, ureter and ipsilateral bladder cuff. The distal ureter can be managed either by extravesical or transvesical approach, whereas endoscopically assisted procedures are associated with decreased intravesical recurrence-free survival. Post-operative intravesical chemotherapy decreases the risk of subsequent bladder tumour recurrence. Regional lymph node dissection is of prognostic importance in infiltrative UTUC, but its extent has not been standardized. Renal-sparing surgery is an option for manageable, high-grade tumours of any part of the upper tract, especially of the distal ureter, as an alternative to RNU. Endoscopy-based renal-sparing procedures are associated with a higher risk of recurrence and progression. CONCLUSIONS: A multimodal approach should be considered in localized high-risk UTUC to improve outcomes. RNU is the standard of treatment in high-risk disease. Renal-sparing approaches may be oncologically equivalent alternatives to RNU in well-selected patients, especially in those with distal ureteric tumours.
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