Ureteric / Upper-Tract Urothelial — treatment notes

8Ureteric / Upper-Tract Urothelial

Snapshot. UTUC (upper-tract urothelial carcinoma) — same urothelial lineage as bladder, but in the renal pelvis or ureter. A "field-change" disease: the whole urothelium is at risk, so bladder recurrence afterwards is common. Stratify like bladder: grade (low vs high) + invasion (non-invasive vs invasive), then localised vs metastatic. Risk factors: smoking, aristolochic acid, Lynch syndrome — UTUC is a Lynch-associated cancer.

Workup

CT urogram (the key study for the upper tracts) · ureteroscopy + biopsy + selective cytology · cystoscopy to exclude a concurrent bladder tumour · renal function — assess BEFORE surgery, not after (drives chemo eligibility) · Lynch-syndrome screen (MMR/MSI).

Treatment by setting

Setting	Treatment
Low-grade, non-invasive	Kidney-sparing where feasible endoscopic (ureteroscopic) ablation, or segmental ureterectomy — especially distal ureter / solitary kidney ± intracavitary chemo
High-grade or invasive radical nephroureterectomy candidate	Radical nephroureterectomy with bladder cuff + a SINGLE post-op intravesical chemotherapy instillation mitomycin — cuts bladder recurrence ADJUVANT platinum chemo (gemcitabine-platinum ×4) for pT2–T4 or pN+ (POUT) the evidence-based standard — 5-yr disease-free survival 62% vs 45% with surveillance ⚠ TIMING TRAP — assess cisplatin fitness BEFORE surgery nephroureterectomy removes a kidney and often drops CrCl below 60, making the patient permanently cisplatin-ineligible for the adjuvant course POUT supports · neoadjuvant cisplatin has NO phase-3 support in UTUC (unlike bladder) — decide the sequence deliberately, don't default to "give it adjuvant" and lose the window Cisplatin-unfit after surgery → adjuvant nivolumab (CheckMate-274) trial eligibility included upper-tract disease
Metastatic	Treated as urothelial carcinoma → EV + pembrolizumab first-line enfortumab vedotin — see Bladder, §3

Watch

Bladder recurrence is common (field change) — lifelong surveillance cystoscopy. Falling renal function after nephroureterectomy can remove cisplatin as an option — this is why fitness is assessed before, not after, surgery. Lynch syndrome → screen patient + family.