Overview of UTUC: from Diagnosis to Treatment to Surveillance

Kay Seong NgooMalaysia Speaker Overview of UTUC: from Diagnosis to Treatment to SurveillanceUpper tract urothelial carcinoma (UTUC) accounts for approximately 5% to 10% of all urothelial carcinomas, with an annual incidence of about 2 per 100,000 population. It predominantly affects men, who are typically diagnosed at a younger age. At the time of diagnosis, approximately two-thirds of UTUC cases involve the intrarenal collecting system, 70% are high-grade, and around two-thirds are invasive. Established risk factors include cigarette smoking, exposure to aristolochic acid, and Lynch syndrome. The majority of patients present with locally advanced disease. Diagnostic workup typically includes contrast-enhanced computed tomography (CT) urography, ureteroscopy with tissue biopsy, and selective urinary cytology. Technological advancements in ureteroscopy, including the integration of optical coherence tomography and confocal laser endomicroscopy, have shown promise in improving in vivo tumour grading and staging. Treatment strategies are guided by risk stratification and the potential for disease progression. In low-risk cases—and in selected high-risk patients with imperative indications—nephron-sparing approaches such as endoscopic ablation, segmental ureterectomy, and chemoablation may be considered. Recent evidence suggests comparable oncologic outcomes between nephron-sparing surgery (NSS) and radical approaches. Advances in endoscopic techniques, including newer laser technologies, have further improved the feasibility and efficacy of NSS. Due to higher recurrence rates following NSS, adjuvant intraluminal therapy is recommended. For high-risk UTUC, radical nephroureterectomy with bladder cuff excision remains the gold standard, irrespective of surgical modality. This is typically followed by a single postoperative intravesical instillation of chemotherapy. Adjuvant platinum-based chemotherapy has demonstrated improved disease-free survival, and emerging data suggest a potential role for immunotherapy in the perioperative setting. Given the high risk of local recurrence, especially after nephron-sparing interventions, long-term and rigorous surveillance is essential. This includes periodic CT urography, cystoscopy, and urinary cytology. Surveillance protocols vary across guidelines, particularly in terms of recommended frequency and duration.