Upper Tract Urothelial Carcinoma

Question 1

Risk factors for suspected UTUC

Answer 1

Age
Male gender
Occupational exposure
Balkan nephropathy (aristolochia)
Chronic inflammation
Lynch syndrome (colorectal, ovarian, entometrial, biliary, small bowel, pancreas, prostate, skin, brain cancers)

Question 2

Initial workup for suspected UTUC

Answer 2

CBC BMP
Cysto
Cross-sectional imaging with delayed phase (CTU or MRU, RGP with noncon imaging
Cytology
Diagnostic ureteroscopy with biopsy
Consider volumetry or renal scan

Question 3

Diagnostic URS procedural recommendations

Answer 3

Manage bladder lesions at the same time
Avoid sheath
Do not interrogate normal side
Send for microsatellite or IHC if suspicion for Lynch

Question 4

What is Lynch Syndrome

Answer 4

Autosomal dominant
-Most likely colorectal, urothelial, gastric, endometrial, ovarian cancers

Question 5

Categorization of UTUC

Answer 5

Low risk - non-invasive, LG path, normal cytology
High risk - invasive, HG, positive cytology

Question 6

Management options and counseling

Answer 6

WW
Ablation +/- postop chemo (BCG, Mitogel)
NAC (cisplatin) if postop GFR will be low and high risk
Partial ureterectomy + intravesical chemo
NephU with bladder cuff + LND + intravesical chemo
Counsel on postop GFR (volumetry or renal scan) and consider nephrology consult
Adjuvant chemo if advanced disease
Adjuvant nivo if ineligible for cisplatin (or prefer it)M

Question 7

Management of metastatic UTUC

Answer 7

Don’t do surgery up front
systemic therapy, consolidative surgery if needed

Question 8

Surveillance for UTUC

Answer 8

Cysto and upper tract endoscopy 1-3 mo nths later
Cysto every 6 months for 2 years, then annually
Endoscopy q6mo
Upper tract imaging q6mo