Bladder Cancer Guidelines

Updated: May 18, 2017
  • Author: Gary David Steinberg, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
  • Print
Guidelines

Guidelines Summary

Organizations and Recommendation Approaches

Guidelines for the diagnosis and management of bladder cancer have been issusued by the following organizations:

  • American Urological Association/Society of Urological Oncology (AUA/SUO)
  • European Association of Urology (EAU)
  • European Society of Medical Oncology (ESMO)
  • National Comprehensive Cancer Network (NCCN)

Each organization uses a different methodology to determine levels of evidence and grades for recommendations, as follows:

  • AUA/SUO – Guideline recommendations are based on literature review or expert consensus. The evidence strength is rated based on level of certainty from A (high certainty) to C (low certainty) and the magnitude and balance between benefits and risks/burdens. Recommendations range from Strong (substantial beneift of harm), Moderate (moderate benefit or harm), Conditional ((No apparent net benefit or harm), Clinical Statement (clinical care that is widely agreed upon by urologists or other clinicians with or without medical evidence) or Expert Opinion (consensus of the panel based on members' clinical training, experience, knowledge, and judgment). [132]
  • EAU - Guideline recommendations have been graded on the basis of the Oxford Centre for Evidence-based Medicine levels of Evidence; however, the link between the level of evidence and grade of recommendation is not directly linear (eg, overwhelming clinical experience and consensus may compensate for absence of high-level evidence [133, 134]
  • ESMO - Guideline recommendations are graded A (strongly recommended) through E (never recommended) based on the Infectious Diseases Society of America–United States Public Health Service Grading System [135]
  • NCCN - Recommendations are derived from critical evaluation of evidence, integrated with the clinical expertise and consensus of a multidisciplinary panel of cancer specialists, clinical experts and researchers in those situations where high-level evidence does not exist [45] ; all guideline recommendations are category 1 (supported by uniform consensus based on high-level evidence) or category 2A (uniform consensus based on lower-level evidence)
Next:

Screening

In 2011, the US Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to determine the balance of benefits and harms of screening for bladder cancer in asymptomatic adults. Although adults with mild lower urinary tract symptoms (eg, urinary frequency, hesitancy, urgency, dysuria, nocturia) are not strictly asymptomatic, these symptoms are common and are not believed to be associated with an increased risk of bladder cancer. The USPSTF considered it reasonable to include these persons in the population under consideration for screening. Adults with gross hematuria or acute changes in lower urinary tract symptoms were not included in this population. [136]

No major organization recommends screening for bladder cancer in asymptomatic adults. In 2011, the American Academy of Family Physicians endorsed the USPSTF recommendation. [137]  The American Cancer Society states that prompt attention to bladder symptoms is the best approach for finding bladder cancer in its earliest, most treatable stages in persons with no known risk factors. [138]

Previous
Next:

Risk Reduction

Cigarette smoking is the most established risk factor for bladder cancer, increasing relative risk four- to five-fold relative to never smoking for current smokers and two- to three-fold for former smokers. It is the cause of 50% of cases in both men and women  [22]

The European Association of Urology (EAU) guidelines estimate a 40% reduction in the risk of developing bladder cancer within 1-4 years of quitting smoking, increasing to a 60% reduction after 25 years of smoking cessation. [133]

In addition, the EAU guidelines address the second most important risk factor, occupational exposure to carcinogens, with a recommendation that workers are informed of the risk and protective measures are taken. [133]

Previous
Next:

Diagnosis

The following studies are used in the diagnosis of bladder cancer:

  • Urinary cytology
  • Urinary tract imaging
  • Cystoscopy
  • Histologic examination of specimens obtained by transurethral resection of the bladder tumor (TURBT)

Novel molecular and genetic markers have been studied for the diagnosis of urothelial carcinoma (see Urine Tumor Markers in Bladder Cancer Diagnosis) but have not been shown to effectively replace urine cytology and cystoscopy. The National Comprehensive Cancer Network guidelines advise that urinary biomarker testing with FDA-approved fluorescence in situ hybridization or nuclear matrix protein 22 (NMP-22) assays may be used in the monitoring or surveillance for bladder cancer recurrence. [45]

Urinary Cytology

According to European Association of Urology (EAU) guidelines, urinary cytology is most helpful in diagnosing high-grade tumors and carcinoma in situ (CIS). Low-grade, noninvasive tumors may be missed by routine cytologic analysis. The guidelines caution that cystoscopy is still required and cannot be replaced by cytology or any other noninvasive test. [134] National Comprehensive Cancer Network (NCCN) guidelines state that urine cytology may be obtained around the time of cystoscopy. [45]

Cystoscopy

In 2016, joint guidelines were issue by the American Urological Association and Society of Urological Oncology that recommended at the time of resection of suspected bladder cancer, a clinician should perform a thorough cystoscopic examination of a patient’s entire urethra and bladder that evaluates and documents tumor size, location, configuration, number, and mucosal abnormalities. In a patient with non–muscle invasive bladder cancer (NMIBC), blue light cystoscopy, if available, should be offered at the time of TURBT to increase detection and decrease recurrence. In a patient with normal cystoscopy and positive cytology and a history of NMIBC, blue light cystoscopy (when available), prostatic urethral biopsies and upper tract imaging, as well as ureteroscopy, or random bladder biopsies should be considerd. [132]

The EAU allows for the omission of cystoscopy if the tumor was visualized with an imaging study. [134]

The NCCN also recommends cystoscopy for all patients with clinical suspicion of bladder cancer. When cystoscopy findings are negative in the setting of positive cytology findings, the NCCN guidelines recommend further evaluation of the upper urinary tract with radiographic imaging and/or ureteroscopy, [45] as well as evaluation of the prostatic urethra in men and the urethra in women.

In general, it may be preferable to obtain upper tract imaging with intravenous contrast for patients with hematuria prior to performing cystoscopy. If the imaging findings are positive, one may forgo office-based cystoscopy and perform the cystoscopy in the operating room. In addition, photodynamic diagnosis with hexaminolevulinate blue-light cystoscopy may be associated with fewer false negatives than white-light cystoscopies. [132, 107]

If cystoscopy indicates noninvasive disease, the NCCN guidelines recommend the following further studies [45] :

  • Imaging of the upper tract collecting system
  • If the cystoscopic appearance of the tumor is solid (sessile) or high-grade, consideration of a CT scan or MRI of the abdomen and pelvis before the TURBT

For imaging of the upper tract, CT urography is generally the preferred approach. Other options are an intravenous pyelogram (IVP), renal ultrasound with retrograde pyelogram, ureteroscopy, or MRI urogram. If the tumor has a purely papillary appearance or only the mucosa appears to be abnormal, suggesting carcinoma in situ (CIS), upper tract imaging can be deferred until after surgery.

If cystoscopy indicates muscle-invasive disease, the NCCN guidelines recommend the following [45] :

  • Complete blood count and chemistry profile including alkaline phosphatase
  • Chest imaging
  • Imaging of the upper tract collecting system
  • Abdominal/pelvic CT or MRI before TURBT
  • Bone scan if alkaline phosphatase level is elevated or patient is symptomatic with bone pain 

In patients with confirmed muscle-invasive bladder cancer, the EAU recommends CT of the chest, abdomen, and pelvis as optimal for staging. The imaging studies should include excretory-phase CT urography for complete examination of the upper urinary tract. [139]

Transurethral Resection of the Bladder Tumor

The guidelines (AUA, EAU, ESMO, NCCN) are in agreement that the final diagnosis of bladder cancer is based on cystoscopic examination and TURBT histology. [133, 132, 134, 135, 45] The guidelines further agree that all visible lesions be resected during TURBT with bimanual examination under anesthesia (EUA) and that adequate sampling is required for proper tumor identification and staging. [133, 132, 134, 135, 45]

EUA guidelines recommend a second TURBT be performed 2-6 weeks after the initial resection in any of the following situations [134] :

  • After incomplete initial TURBT
  • If there is no muscle in the specimen after initial resection, with exception of Ta low-grade tumors and, possibly, completely resected primary carcinoma in situ (CIS)
  • In all T1 tumors
  • In all high-grade tumors, except primary CIS; however, it may be beneficial to attempt to resect all CIS lesions at repeat TURBT

 

Previous
Next:

Staging

Bladder cancer is staged using the International Union Against Cancer and the American Joint Committee on Cancer Staging’s tumor, node, and metastases (TNM) system. [77] See Bladder Cancer Staging.

Ta and T1 tumors and carcinoma in situ (CIS) were historically considered superficial bladder tumors. T2, T3, and T4 tumors were traditionally described as invasive bladder cancer. However, use of the term superficial bladder cancer is recommended against by the AUA/SUO, NCCN and EAU guidelines because it groups together patients who may require different treatments and who may have different prognoses. Instead, all guidelines now categorizes these tumors as non–muscle invasive bladder cancer (NMIBC). [132, 134, 135, 45]

Urothelial carcinoma is histologically graded as low grade (formerly grades 1-2) or high grade (formerly some grades 2 and all grades 3). CIS is characterized by full mucosal thickness and high-grade dysplasia or marked atypia of the bladder epithelium and is associated with a poorer prognosis. By definition, CIS is confined to the epithelial surface of the urinary tract and has no other official stage definition.

The EAU uses three levels of risk stratification for non–muscle-invasive tumors, as follows [134] :

  • Low risk: Primary, solitary, Ta, low grade, <3 cm
  • Intermediate risk: All tumors not meeting the definition of either low- or high-risk tumors
  • High risk: T1 tumor; any high-grade tumor including Ta, CIS, or multiple, recurrent and large (>3 cm) Ta tumors (all conditions must be present)

 

Previous
Next:

Treatment

Non─Muscle-Invasive Disease

National Comprehensive Cancer Network (NCCN) recommendations for treatment of low-grade Ta tumors are as follows [45] :

  • Standard treatment for non–muscle invasive bladder cancer (NMIBC) is a complete transurethral resection of the bladder tumor (TURBT)
  • Intravesical chemotherapy is generally used as prophylactic or adjuvant therapy after complete endoscopic resection; it is rarely used as therapy to eradicate residual disease that could not be completely resected
  • One postoperative intravesical dose (within 24 h, but usually immediately after resection) has been shown to reduce recurrence, but not progression, of disease for patients with low-risk NMIBC
  • Immediate intravesical chemotherapy is avoided when TURBT was extensive or perforation is suspected or the tumor appears invasive or high grade
  • Immediate intravesical chemotherapy can be followed by a 6-week induction of intravesical chemotherapy
  • Immunotherapy may be used but is not recommended

NCCN and European Association of Urology (EAU) recommendations for treatment of high-grade Ta tumors are as follows [134, 45] :

  • TURBT should be repeated if there is incomplete resection; if no muscle is present in the specimen, strongly consider repeating resection. In addition, repeat TURBT has prognostic, therapeutic, and surveillance indications: Up to 40-70% of patients will have residual bladder cancer at repeat TURBT performed within 4-6 weeks after initial TURBT
  • Intravesical immunotherapy bacillus Calmette-Guérin (BCG) after TURBT is recommended and is superior to intravesical chemotherapy for preventing tumor recurrence [132, 134]

NCCN recommendations for treatment of T1 tumors (low- and high-grade) are as follows [45] :

  • Repeat TURBT
  • If no residual disease after second resection, immunotherapy with BCG (category 1 recommendation)
  • If residual disease after second resection, immunotherapy with BCG (category 1 recommendation), especially if the disease is Ta high grade or carcinoma in situ
  • Consider cystectomy for T1 high grade and cystectomy for any patients upstaged to T2

The European Association of Urology (EAU) recommendations for adjuvant treatment of Ta and T1 tumors are as follows [134] :

  • In low-risk Ta tumors, one immediate instillation of chemotherapy is recommended as the complete adjuvant treatment
  • In intermediate-risk Ta or T1 tumors, one immediate instillation of chemotherapy should be followed by 1 year of full-dose BCG treatment, or by further instillation of chemotherapy for a maximum of 1 year
  • In high-risk tumors, full-dose intravesical BCG for 1-3 years or radical cystectomy is recommended
  • In T1 high grade and concurrent CIS, cystectomy should be considered
  • In BCG-refractory tumors, cystectomy is recommended; bladder-preserving strategies are recommended in patients not suitable for or refusing radical cystectomy

The AUA/SUO recommendations for repeat TURBT are as follows [132] :

  • In patients with incomplete initial resection, repeat TURBT if technically feasible
  • For high-risk, high grade Ta tumors, consider performing repeat TURBT of the primary tumor site within 6 weeks of initial TURBT
  • In T1 disease, repeat TURBT of the primary tumor site including muscularis propria within 6 weeks of initial TURBT

The AUA/SUO recommendations for intravesical therapy are as follows [132] :

  • For low- or intermediate-risk bladder cancer, consider a single postoperative instillation of intravesical chemotherapy (e.g., mitomycin C or epirubicin) within 24 hours of TURBT.
  • After an extensive resection or if a perforation is suspected, postoperative chemotherapy should not be administered. 
  • Induction intravesical therapy should not be given to low-risk patients. 
  • Consider a six week course of induction intravesical chemotherapy or immunotherapy for intermediate-risk bladder cancer. 
  • In a high-risk patient with newly diagnosed CIS, high-grade T1, or high-risk Ta urothelial carcinoma, a six-week induction course of BCG. 
  • In an intermediate-risk patient who completely responds to an induction course of intravesical chemotherapy, maintenance therapy may be given.
  • In an intermediate-risk patient who completely responds to induction BCG, consider maintenance BCG for one year, as tolerated. 
  • In a high-risk patient who completely responds to induction BCG, continue maintenance BCG for three years, as tolerated. 

Carcinoma in situ

The NCCN recommendations are as follows [45] :

  • Resection followed by intravesical therapy with BCG once a week for 6 weeks, followed by a rest period of 6 weeks
  • Full re-evaluation at week 12 (ie, 3 months) after the start of therapy
  • If the patient is unable to tolerate BCG, intravesical mitomycin C may be administered (however, most patients can tolerate BCG with dose reductions and anticholinergic medication)
  • Follow-up is similar to that for T1 and Ta high-grade tumors

Follow-up and Surveillance

The European Association of Urology (EAU) guidelines recommend regular cystoscopy for follow-up of patients with Ta, T1 tumors and carcinoma in situ (CIS) who have undergone transurethral resection of the bladder tumor. Schedules are as follows [134] :

  • Patients with low-risk Ta tumors should undergo cystoscopy at 3 months, then (if no evidence of disease is found) 9 months later, then yearly for 5 years
  • Patients with high-risk tumors should undergo cystoscopy and urinary cytology at 3 months, then every 3 months for 2 years, every 6 months thereafter until 5 years, then yearly
  • Patients with intermediate-risk Ta tumors should have follow-up cystoscopy and cytology on a schedule that is in between those for low- and high-risk tumors and that is adapted according to personal and subjective factors
  • Annual upper tract imaging (CT urography or intravenous urography) is recommended for high-risk tumors (note, however, that there are no data to support annual imaging for asymptomatic, recurrence-free patients)
  • Patients with suspicious findings on cystoscopy or positive urine cytology should undergo endoscopy under anesthesia and bladder biopsies (these patients may benefit from photodynamic detection with hexaminolevulinate blue-light cystoscopy)
  • In patients with CIS, consider random biopsies (these are rarely informative) or biopsies with photodynamic diagnosis at 3 or 6 months after intravesical treatmentDuring follow-up in patients with positive cytology and no visible tumor in the bladder, random biopsies or biopsies with photodynamic diagnosis and investigation of extravesical locations (CT urography, prostatic urethra biopsy) are recommended

The NCCN guidelines specify that cystoscopy and urinary cytology should be performed every 3-6 months for 2 years and then at increasing intervals as appropriate. [45]

The AUA/SUO guidelines recommended surveillance schedules are as follows [132] :

  • First surveillance cystoscopy within 3-4 months of the initial evaluation and treatment 
  • For a low-risk patient whose first surveillance cystoscopy is negative, subsequent cystoscopy 6-9 months later, and then annually thereafter; after 5 years, continued surveillance should be based on shared-decision making between the patient and clinician.
  • In an asymptomatic patient with a history of low-risk NMIBC, routine surveillance upper tract imaging should not be performed.
  • For an intermediate-risk patient whose first surveillance cystoscopy is negative,  subsequent cystoscopy with cytology every 3-6 months for 2 years, then 6-12 months for years 3 and 4, and annually thereafter.
  • For a high-risk patient whose first surveillance cystoscopy is negative, subsequent cystoscopy with cytology every 3-4 months for 2 years, then 6 months for years 3 and 4, and then annually thereafter.
  • For an intermediate- or high-risk patient, a clinician should consider performing surveillance upper tract imaging at 1-2 year intervals. 

Muscle-Invasive Disease

NCCN recommendations for treatment of muscle-invasive disease are as follows  [45] :

  • Transurethral resection of the bladder tumor (TURBT) is the initial diagnostic procedure after CT/MRI imaging of the abdomen, pelvis, and in some cases the chest, to help identify the clinical stage of the bladder cancer
  • Radical cystectomy is the primary treatment for all muscle-invasive disease, with strong consideration for cisplatin-based neoadjuvant chemotherapy (category 1 recommendation), especially for patients with hydronephrosis, vascular/lymphatic invasion, extravesical disease, or aberrant histologic variants.
  • Neoadjuvant chemotherapy may be preferred over adjuvant chemotherapy; however, there are no data to support this preference
  • Regimens include DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin) with growth factor support for three or four cycles; gemcitabine and cisplatin for three or four cycles (both 21- and 28-day regimens are acceptable); or accelerated-dose MVAC for three cycles
  • The NCCN panel prefers DDMVAC over standard MVAC, based on category 1 evidence that DDMVAC is better tolerated and more effective than conventional MVAC in advanced disease
  • Partial cystectomy may be performed in highly selected patients with a solitary lesion in a suitable location and no carcinoma in situ (CIS) or previous tumors; cisplatin-based neoadjuvant chemotherapy should be considered
  • Bladder preservation following TURBT with concurrent chemotherapy and radiation is an alternative therapy for patients with multiple medical co-morbidities or who refuse radical cystectomy; the decision should be based, in part, on the location, size and depth of invasion, and absence of hydronephrosis, as well as the bladder capacity, function, and comorbidities

For patients with advanced or metastatic disease, first-line chemotherapy regimens are as follows:

  • Gemcitabine and cisplatin (category 1 recommendation)
  • DDMVAC with growth factor support (category 1 recommendation)

For patients who cannot receive cisplatin-based chemotherapy due to renal impairment or other comorbidities, carboplatin- or taxane-based regimens, or single-agent therapy may be considered.

The NCCN considers that there are no definitive recommendations for second-line therapy; clinical trials of new agents is recommended. For example, studies of immunotherapy with programmed cell death–1 (PD-1) protein/PD-1 ligand checkpoint inhibitors (eg, MPDL3280A) are being conducted.

The choice of agents for palliative therapy depends on the chemotherapy that was used for first-line treatment; for example, although the NCCN includes single-agent cisplatin as an option, most of the patients who require second-line therapy have not responded to cisplatin and need an alternative chemotherapy or immunotherapy regimen. Single-agent taxane or gemcitabine is preferred. Additional options include the following:

  • Carboplatin
  • Doxorubicin
  • 5-fluorouracil (5-FU)
  • Ifosfamide
  • Pemetrexed
  • Methotrexate
  • Vinblastine

The European Association of Urology (EAU) recommends radical cystectomy as the curative treatment of choice for muscle-invasive disease. [133]  The EAU recommends pelvic lymph node dissection (LND) as a means of improving survival after radical cystectomy; however, it should be noted that no data exist to support this recommendation. Ongoing studies are assessing whether survival is influenced by the use of standard versus extended LND—ie, whether the cephalad margin should extend to the iliac arteries (standard) or to the aortic bifurcation (extended).

Further EAU recommendations for muscle-invasive disease are as follows [133] :

  • The urethra may be preserved if margins are negative
  • Laparoscopic and robotic-assisted laparoscopic cystectomy is feasible but still investigational
  • Neoadjuvant chemotherapy is recommended and should always be cisplatinum-based combination therapy
  • Multimodality treatment could be offered as an alternative in well-informed, well selected and compliant patients, especially for whom cystectomy is not an option
  • External beam radiotherapy alone should only be considered as a therapeutic option when the patient is unfit for cystectomy or a multimodality bladder-preserving approach
  • In inoperable locally advanced tumors (T4b), primary radical cystectomy is a palliative option and cannot be offered as curative treatment
  • TURBT alone cannot be offered as a standard curative treatment option in most patients
  • Chemotherapy alone is not recommended as primary therapy

For patients with advanced or metastatic disease, first-line chemotherapy consists of the following cisplatin-containing combination regimens:

  • Gemcitabine plus cisplatin (GC)
  • Paclitaxel, cisplatin, and gemcitabine (PCG)
  • Methotrexate, vinblastine, Adriamycin (doxorubicin), and cisplatin (MVAC), preferably with granulocyte colony-stimulating factor (G-CSF)
  • High-dose MVAC (HD-MVAC) with G-CSF
  • For cisplatin-ineligible patients, treatment with carboplatin-containing combination chemotherapy, preferably with gemcitabine/carboplatin is indicated.

Second-line treatment is as follows:

  • In patients progressing after platinum-based combination chemotherapy for metastatic disease, vinflunine may be considered (efficacy is limited, however, with no prolongation of cancer-free or overall survival)
  • Alternatively, treatment within a clinical trial setting may be offered
  • Zoledronic acid or denosumab is recommended for treatment of bone metastases
  • European Society for Medical Oncology (ESMO) recommendations for treatment of metastatic disease are as follows [135] :
  • Radical cystectomy with pelvic lymphadenectomy
  • Age is not a limiting factor for surgery (however, 6-month overall survival is lower in octagenarians than in patients younger than age 80)
  • Organ preservation therapy is reasonable for patients seeking an alternative to cystectomy or as a palliative treatment for those who are medically unfit for surgery
  • External beam radiotherapy may be considered as part of a multimodality bladder-preserving approach
  • Cisplatin-based neoadjuvant chemotherapy is appropriate before radical cystectomy or radiotherapy; standard regimens include GC and MVAC

For patients who cannot receive cisplatin-based chemotherapy, palliation with carboplatin-based regimen or single-agent taxane or gemcitabine

There is insufficient evidence for the routine use of adjuvant chemotherapy; high-risk patients that did not receive neoadjuvant chemotherapy may benefit form adjuvant treatment.

When the patient is unfit for cystectomy, radiotherapy can also be offered for palliation (bleeding, pain)

Previous
Next:

Upper Urinary Tract Urothelial Cell Carcinoma

Diagnosis

The NCCN and EAU provide similar recommendations for the diagnosis of upper tract urothelial carcinoma (UTUC), which include cystology, cystoscopy (to rule out a concomitant bladder tumor), and CT (computed tomography) urography.  [45, 139] . The EAU further recommends retrograde ureteropyelography and diagnostic ureteroscopy and biopsy. [139]

Treatment

The NCCN provides treatment recommendations based on the location and disease extent, as follows [45] :

  • Tumors that originate in the upper ureter typically are treated with nephroureterectomy with a cuff of bladder plus regional lymphadenectomy for high-grade tumors; a portion of the bladder is removed to ensure complete removal of the entire intramural ureter
  • Endoscopic resection of upper ureter tumors is acceptable
  • Tumors that originate in the mid-portion are divided by grade and size
  • Treatment of small, low-grade tumors is excision and ureteroureterostomy or complete ureterectomy and ileal ureter in highly selected patients; endoscopic resection; or, if the tumor cannot be managed endoscopically and the ureteral extent is too great, nephroureterectomy with a cuff of bladder may be considered
  • Nephroureterectomy with a cuff of bladder and regional lymphadenectomy for larger, high-grade lesions; neoadjuvant chemotherapy should be considered for selected patients
  • Distal ureteral tumors may be managed with a distal ureterectomy and reimplantation of the ureter (preferred if clinically feasible), endoscopic resection, or, in some cases, a nephroureterectomy with a cuff of bladder, with the addition of regional lymphadenectomy recommended for high-grade tumors

The EUA provides conservative management recommendations, as well as recommendations for radical nephroureterectomy (RNU). The indications for RNU are as follows: [139]

  • Suspicion of infiltrating UTUC on imaging
  • High-grade tumor
  • Multifocality (with two functional kidneys)
  • Noninvasive but large (>2 cm) UTUC
  • Neoadjuvant chemotherapy should be considered in all of these categories (however, this has not been adequately studied in randomized clinical trials)

Recommendations regarding RNU include the following:

  • Open and laparoscopic access are equivalent in terms of efficacy
  • Bladder cuff removal is imperative
  • Several techniques for bladder cuff excision are acceptable, except stripping
  • Lymphadenectomy is recommended
  • Postoperative instillation chemotherapy in the bladder may prevent recurrence

The indications for conservative management are as follows:

  • Unifocal tumor
  • Tumor <1 cm
  • Low-grade tumor
  • No evidence of an infiltrative lesion on CT urography
  • Understanding of close follow-up

Recommendations regarding conservative treatment include the following:

  • Flexible ureteroscopy is preferable to rigid ureteroscopy
  • A percutaneous approach remains an option in small, low-grade calyceal tumors unsuitable for ureteroscopic treatment
  • Ureteroureterostomy for noninvasive low-grade tumors of the proximal ureter or mid-ureter that cannot be removed completely by endoscopic means, and for high-grade or invasive tumors when renal sparing surgery (RSS) for preservation of renal function is a goal
  • Complete distal ureterectomy and neocystostomy for non-invasive, low-grade tumors in the distal ureter that cannot be removed completely by endoscopic means and for high-grade, locally-invasive tumors

Follow-up and surveillance

The EAU recommends follow-up for at least 5 years after treatment of UTUC; however, the surveillance schedules specified are all grade C recommendations. Surveillance schedules are as follows [139] :

  • Noninvasive tumors treated with RNU - Cystoscopy and urinary cytology at 3 months and then annually; CT annually
  • Invasive tumors treated with RNU - Cystoscopy and urinary cytology at 3 months and then annually; CT urography every 6 months over 2 years and then annually
  • Conservatively managed tumors - Urinary cytology and CT urography at 3, 6, and 12 months and annually thereafter; cystoscopy, ureteroscopy, and cytology in situ at 3 and 6 months, then every 6 months over 2 years, then annually
Previous