Treatment of Renal Pelvis Cancer with High-Grade Urine Cytology and High-Risk UTUC Features, No Distant Metastases
This protocol applies to patients with upper urinary tract urothelial carcinoma (UTUC) who present with at least one high-risk feature — most notably high-grade urine cytology — in the absence of distant metastases. The presence of any qualifying high-risk factor defines the approach.
Clinical Scenario
Upper urinary tract urothelial carcinoma with at least one of the following high-risk criteria:
- High-grade urine cytology
- High-grade ureteroscopy biopsy
- Local invasion on CT imaging
- Histological urothelial carcinoma subtype
No distant metastases are present. A single qualifying factor is sufficient to classify the tumour as high-risk.
Approach
For this high-risk, non-metastatic setting, the cornerstone of management is radical surgical removal of the kidney and ureter — radical nephroureterectomy (RNU). This may be carried out via open, laparoscopic, or robotic technique, with structured lymph node dissection as a component of the procedure. A single adjunctive local bladder measure is considered in eligible patients in the postoperative period.
The full protocol — including complete procedural details, patient selection criteria, sequencing, and all additional management steps — is available via the structured regimen below.
References
DOI: 10.1016/j.eururo.2025.02.023
- Strong criteria for high risk definition: High-grade cytology, High-grade URS biopsy, Local invasion on CT, Histological subtype.
- Any of these factors needs to be present.
- Perform RNU in patients with high-risk nonmetastatic UTUC.
- Use an open, laparoscopic, or robotic approach to perform RNU in patients with high-risk nonmetastatic UTUC.
- Perform template-based lymphadenectomy in patients with high-risk nonmetastatic UTUC.
- Perform en bloc removal of the kidney, ureter, and bladder cuff.
- Deliver a postoperative bladder instillation of chemotherapy to reduce the intravesical recurrence rate in patients without a history of bladder cancer.
- Two prospective randomised trials and two meta-analyses have demonstrated that a single postoperative dose of intravesical chemotherapy (mitomycin C or pirarubicin) 2–10 d after surgery reduces the risk of bladder tumour recurrence within the first years after RNU for patients without a history of BC.
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