Upper Urinary Tract Urothelial Cell Carcinoma

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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M. Rouprêt,, M. Babjuk, M. Burger, E. Compérat, N.C. Cowan, P. Gontero,, A.H. Mostafid, J. Palou, B.W.G. van Rhijn, S.F. Shariat, R. Sylvester, R. Zigeuner
Guidelines Associates: J.L. Dominguez-Escrig, B. Peyronnet, T. Seisen

1.INTRODUCTION

1.1.Aim and objectives

The European Association of Urology (EAU) Non-muscle-invasive Bladder Cancer (NMIBC) Guidelines Panel has compiled these clinical guidelines to provide urologists with evidence-based information and recommendations for the management of urothelial carcinoma of the upper urinary tract (UTUC). Separate EAU guidelines documents are available addressing non-muscle-invasive bladder cancer [1], muscle-invasive and metastatic bladder cancer (MIBC) [2], and primary urethral carcinoma [3].

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The European Association of Urology (EAU) Guidelines Panel on NMIBC consists of an international multidisciplinary group of clinicians, including urologists, uro-oncologists, a radiologist, a pathologist and a statistician. Members of this panel have been selected based on their expertise and to represent the professionals treating patients suspected of harbouring urothelial carcinoma. All experts involved in the production of this document have submitted potential conflict of interest statements, which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/upper-urinary-tract-urothelial-cell-carcinoma/.

1.3.Available publications

A quick reference document (Pocket guidelines) is available in print and as an app for iOS and Android devices, presenting the main findings of the UTUC Guidelines. These are abridged versions which may require consultation together with the full text version. Several scientific publications are available as are a number of translations of all versions of the EAU UTUC Guidelines, the most recent scientific summary was published in 2017 [4]. All documents are accessible through the EAU website Uroweb: http://uroweb.org/guideline/upper-urinary-tract-urothelial-cell-carcinoma/.

1.4.Publication history & summary of changes

The first EAU Guidelines on UTUC were published in 2011. The 2018 EAU Guidelines on UTUC present a limited update of the 2017 version.

1.4.1.Summary of changes

The literature for the complete document has been assessed and updated, whenever relevant. Conclusions and recommendations have been rephrased and added to throughout the current document.

Key changes for the 2018 print:


  • Figure 6.2 - Risk stratification of upper urinary tract urothelial carcinoma, tumour size cut off for high-risk UTUC has been changed to > 2 cm;
  • Section 6.6 - Summary of evidence and guidelines for prognosis – recommendation ‘Use the America Society of Anesthesiologists score to assess cancer-specific survival’ – was taken out;
  • Section 7.1.4.3 - Summary of evidence and recommendations for radical nephroureterectomy.

Recommendations

Strength rating

Perform radical nephroureterectomy in patients with high-risk tumours.

Strong

Technical steps of radical nephroureterectomy:

Offer a post-operative bladder instillation of chemotherapy to lower the intravesical recurrence rate.

Strong

  • Section 8.1: Summary of evidence and follow-up of UTUC

Recommendations

Strength rating

After radical nephroureterectomy:

Low-risk tumour

Perform cystoscopy at three months. If negative, perform subsequent cystoscopy nine months later and then yearly, for five years.

Weak

Perform computed tomography urography every year for five years.

Weak

High-risk tumours

Perform cystoscopy and urinary cytology at three months. If negative, repeat subsequent cystoscopy and cytology every three months for a period of two years, and every six months thereafter until five years, and then yearly.

Weak

Perform computed tomography urography every six months for two years, and then yearly.

Weak

After kidney-sparing management:

Low-risk tumours

Perform cystoscopy and computed tomography urography at three and six months, and then yearly for five years.

Weak

Perform ureteroscopy at three months.

Weak

High-risk tumours

Perform cystoscopy, urinary cytology and computed tomography urography at three and six months, and then yearly.

Weak

Perform ureteroscopy and urinary cytology in situ at three and six months.

Weak

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