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 2023 print can be found in:
- Section 5.7 Summary of evidence and recommendations for the diagnosis of UTUC, the following recommendations were revised:
Recommendations | Strength rating |
2022 recommendation: Use diagnostic ureteroscopy and biopsy if imaging and cytology are not sufficient for the diagnosis and/or risk-stratification of the tumour. | Strong |
Revised 2023 recommendation: Use diagnostic ureteroscopy (preferably without biopsy) if imaging and/or voided urine cytology are not sufficient for the diagnosis and/or risk-stratification of patients suspected to have UTUC. | Strong |
2022 recommendation: Magnetic resonance urography or 18F-Fluorodeoxglucose positron emission tomography/CT may be used when CT is contra-indicated. | Weak |
Revised 2023 recommendation: Magnetic resonance urography or 18F-Fluorodeoxglucose positron emission tomography/CT (to assess [nodal] metastasis) may be used when CT is contra-indicated. | Weak |
- Chapter 7 Disease Management has been restructured resulting in recommendations moved to other sections and new recommendations having been added to Section 7.2.5 Summary of evidence and guidelines for the management of high-risk non-metastatic UTUC:
Summary of evidence | LE |
Post-operative platinum-based adjuvant chemotherapy improves disease-free survival. | 1b |
Recommendations | Strength rating |
New 2023 recommendation: Offer adjuvant platinum-based chemotherapy after RNU to patients with pT2–T4 and/or pN+ disease. | Strong |
New 2023 recommendation: Discuss adjuvant nivolumab with patients unfit for, or who declined, platinum-based adjuvant chemotherapy for > pT3 and/or pN+ disease after RNU alone or > ypT2 and/or ypN+ disease after neoadjuvant chemotherapy, followed by RNU. | Weak |
2022 recommendation: Offer kidney-sparing management to patients with solitary kidney and/or impaired renal function, providing that it will not compromise survival. This decision will have to be made on a case-by-case basis in consultation with the patient. | Strong |
Revised 2023 recommendation: Offer kidney-sparing management to high-risk patients with imperative indication on a case-by-case basis, in consultation with the patient. | Strong |
- New data prompted changes to Figure 7.1 Proposed flowchart for the management of UTUC.
- Section 7.3.3 Summary of evidence and recommendations for the treatment of metastatic UTUC:
Summary of evidence | LE |
Carboplatin-based combination chemotherapy offers a survival benefit in cisplatin unfit patients. | 1b |
Erdafitinib was associated with radiological response in platinum-refractory patients with locally-advanced or metastatic UC and FGFR DNA genomic alterations (FGFR2/3 mutations or FGFR3 fusions). | 2a |
Enfortumab vedotin was associated with OS benefit in patients who had previously received platinum-containing chemotherapy and experienced disease progression during or after treatment with a PD-1 or PD-L1 inhibitor. | 1b |
Palliative nephroureterectomy can improve quality of life by controlling symptomatic disease. | 3 |
RNU can confer a survival benefit in highly selected patients. | 4 |
Recommendations | Strength rating |
First-line treatment for cisplatin-eligible patients | |
New 2023 recommendation: Offer platinum combination chemotherapy to platinum-eligible patients. | Strong |
First-line treatment in patients ineligible for cisplatin or carboplatin | |
New 2023 recommendation: Offer gemcitabine/carboplatin chemotherapy to cisplatin-ineligible patients. | Strong |
2022 recommendation: Offer checkpoint inhibitors pembrolizumab or atezolizumab depending on PD-L1 status. | Weak |
Revised 2023 recommendation: Offer checkpoint inhibitors pembrolizumab or atezolizumab to patients with PD-L1 positive tumours. | Weak |
Second-line treatment | |
New 2023 recommendation: Offer enfortumab vedotin to patients previously treated with platinum-containing chemotherapy and who had disease progression during or after treatment with a PD-1 or PD-L1 inhibitor. | Strong |
2022 recommendation: Offer erdafitinib in platinum-refractory tumours with FGFR alterations. | Strong |
Revised 2023 recommendation: Offer erdafitinib as subsequent-line therapy to platinum-refractory patients with FGFR DNA genomic alterations (FGFR2/3 mutations or FGFR3 fusions). | Weak |
DNA = deoxyribonucleic acid; FGFR = fibroblast growth factor receptors; PD-L1 = programmed death ligand 1.
- Section 8.1 Summary of evidence and recommendations for the follow-up of UTUC:
Recommendations | Strength rating |
After kidney-sparing management | |
Low-risk tumours | |
2022 recommendation: Perform ureteroscopy (URS) at 3 months. | Weak |
Revised 2023 recommendation: Perform ureteroscopy (URS) at 3 months if no second-look ureteroscopy was performed. | Weak |