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1. Laser generator and pliers available for biopsies
(LE: 3)
2. In case a flexible (rather than a rigid) ureteroscope is
available
3. The patient is informed of the need for early (second
look) closer, more stringent, surveillance
4. Complete tumour resection or destruction can be
achieved
Nevertheless, a risk of understaging and undergrading
remains with endoscopic management.
3.5.1.1.2. Percutaneous access. Percutaneous management can
be considered for low-risk UTUC in the renal pelvis
(LE: 3). This may be offered for low-risk tumours in the
lower caliceal system that are inaccessible or difficult to
manage by flexible ureteroscopy. However, this approach is
being used less due to the availability of improved
endoscopic tools such as distal-tip deflection of recent
ureteroscopes . A risk of tumour seeding remains with
a percutaneous access.
3.5.1.1.3. Segmental ureteral resection. Segmental ureteral resec-
tion with wide margins provides adequate pathological
specimens for staging and grading while preserving the
ipsilateral kidney. Lymphadenectomy can also be per-
formed during segmental ureteral resection
Complete distal ureterectomy with neocystostomy are
indicated for low-risk tumours in the distal ureter that
cannot be removed completely endoscopically and for high-
risk tumours when KSS for renal function preservation is
necessary (LE: 3).
Segmental resection of the iliac and lumbar ureter is
associated with higher failure rates than for the distal pelvic
ureter (LE: 3).
Partial pyelectomy or partial nephrectomy is extremely
rarely indicated. Open resection of tumours of the renal
pelvis or calices has almost disappeared.
3.5.1.1.4. Adjuvant topical agents. The antegrade instillation of
bacillus Calmette-Guérin (BCG) vaccine or mitomycin C in
the upper urinary tract by percutaneous nephrostomy via a
three-valve system open at 20 cm (after complete tumour
eradication) is feasible after kidney-sparing management or
for treatment of CIS (LE: 3). Retrograde instillation
through a ureteric stent is also used, but it can be dangerous
due to possible ureteric obstruction and consecutive
pyelovenous influx during instillation/perfusion. The reflux
obtained from a double-J stent has been used but is not
advisable since it often does not reach the renal pelvis.
3.5.1.2. Radical nephroureterectomy. Open RNU with bladder
cuff excision is the standard for high-risk UTUC, regardless
of tumour location (LE: 3; ). RNU must comply
with oncological principles, that is, preventing tumour
seeding by avoidance of entry into the urinary tract during
resection lists the recommendations for RNU.
Resection of the distal ureter and its orifice is performed
because there is a considerable risk of tumour recurrence in
this area After removal of the proximal ureter, it is
difficult to image or approach it by endoscopy. Removal of
the distal ureter and bladder cuff is beneficial after RNU .
Several techniques have been considered to simplify
distal ureter resection, including pluck technique, stripping,
transurethral resection of the intramural ureter, and
intussusception. Except for ureteral stripping, none of these
techniques is inferior to bladder cuff excision
(LE: 3).
3.5.1.2.1. Laparoscopic RNU. Retroperitoneal metastatic dissem-
ination and metastasis along the trocar pathway following
Table 4 – Guidelines for kidney-sparing management of upper tract urothelial carcinoma
Recommendations GR
Offer kidney-sparing management as primary treatment option to patients with low-risk tumours and two functional kidneys. C
Offer kidney-sparing management in patients with solitary kidney and/or impaired renal function, provided that it will not
compromise the oncological outcome. This decision will have to be made on a case-by-case basis, engaging the patient in
a shared decision-making process.
C
Offer a kidney-sparing approach in high-risk cancers for distal ureteral tumours and in imperative cases
(solitary kidney and/or impaired renal function).
C
Use a laser for endoscopic treatment of upper tract urothelial carcinoma. C
GR = grade of recommendation.
Table 5 – Summary of evidence and recommendations for radical
nephroureterectomy
Summary of evidence LE
Radical nephroureterectomy is the standard in high-risk upper
tract urothelial carcinoma, regardless of tumour location.
2
Open and laparoscopic approaches have equivalent efficacy
and safety in T1–2/N0 upper tract urothelial carcinoma.
2
Recommendations GR
Perform radical nephroureterectomy in the following situations:
1. Suspicion of in filtrating upper tract urothelial
carcinoma on imaging
2. High-grade tumour (urinary cytology)
3. Multifocality (with two functional kidneys)
4. Noninvasive but large (>2 cm) upper tract urothelial
carcinoma
B
Technical steps of radical nephroureterectomy
Remove the bladder cuff. A
Perform a lymphadenectomy in invasive upper tract
urothelial carcinoma.
C
Offer postoperative bladder instillation to lower the
bladder recurrence rate.
B
GR = grade of recommendation; LE = level of evidence.
E U R O P E A N U R O L O GY 7 3 ( 2 0 18 ) 111 – 1 2 2 117