The American Urological Association (AUA) and Society of Urologic Oncology (SUO) have released a new guideline on the management of nonmetastatic upper tract urothelial carcinoma (UTUC).

The guideline, published in The Journal of Urology, provides evidence-based recommendations on diagnosis, risk stratification, and treatment of UTUC.

Below is a synopsis of the report’s major recommendations to surgeons.

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Diagnosis and Evaluation

For patients with suspected UTUC, perform cystoscopy and cross-sectional imaging of the upper tract with contrast. In likely cases, perform diagnostic ureteroscopy, biopsy of lesions, and cytologic washing of the upper tract.

When ureteroscopy is not possible, attempt selective upper tract washing or barbotage for cytology. Use pyeloureterography in the absence of CT or magnetic resonance urography.

In patients with high probability of Lynch syndrome-related cancers, perform universal histologic testing of UTUC with additional studies, such as immunohistochemical or microsatellite instability.

Risk Stratification

To facilitate clinical staging and risk assessment, the report recommends documenting the focality, location, appearance, and size of lesions based on endoscopy and recording features such as invasion, obstruction, and lymphadenopathy observed on imaging.

After standardized assessment, stratify patients as “low” or “high” risk for invasive pT2 or higher disease based on endoscopic, cytologic, pathologic, and radiographic findings. Biopsy alone is not sufficient. Further stratify patients into favorable and unfavorable risk groups.


Tumor ablation, a nephron-sparing option, is recommended for patients with favorable low-risk UTUC. Tumor ablation also may be offered to patients with unfavorable low-risk UTUC and select patients with favorable high-risk UTUC who have low-volume tumors or cannot undergo radical nephroureterectomy (RNU). After ablation and ruling out perforation, consider instilling adjuvant pelvicalyceal chemotherapy. When tumor ablation isn’t feasible or progression has occurred, perform RNU or segmental resection of the ureter.

Perform RNU or segmental ureterectomy in suitable high-risk UTUC cases. When performing RNU or distal ureterectomy, excise the entire distal ureter, including the intramural ureteral tunnel and ureteral orifice, and seal the urinary tract. Also perform lymph node dissection. Follow with a single dose of perioperative intravesical chemotherapy. Clinicians also may consider lymph node dissection in low-risk cases.

Clinicians should offer cisplatin-based neoadjuvant chemotherapy to surgical patients with high-risk UTUC. Clinicians should offer platinum-based adjuvant chemotherapy to patients with advanced pathologic stage UTUC after RNU or ureterectomy if they have not received neoadjuvant platinum-based therapy.

Adjuvant nivolumab may be given to patients who received neoadjuvant platinum-based chemotherapy and have ypT2-T4 or ypN+ disease or patients with pT3, pT4a, or pN+ disease who are ineligible for perioperative cisplatin.

The full guideline also provides recommendations for UTUC surveillance using cystoscopy, cytology, upper tract endoscopy, abdominal/pelvic CT or MRI with contrast, and basic metabolic panel. Recommendations and schedules vary for patients with low-risk vs high-risk UTUC who received kidney-sparing approaches and patients with low-stage (less than pT2) vs high-stage UTUC who underwent nephroureterectomy. Clinicians should refer patients with declining kidney function to nephrology. Clinicians should also discuss healthy lifestyle behaviors, such as smoking cessation.

Applying the Guideline

At the AUA’s 2023 Annual Scientific Meeting, guideline chair Jonathan Coleman, MD, of Memorial Sloan Kettering Cancer Center in New York, New York, reviewed highlights from the new guideline. He noted that UTUC is prone to mismanagement and requires a standardized approach. UTUC is the third most common cancer associated with Lynch syndrome — affecting 9%-12% of patients — so he emphasized that clinicians should be screening their patients for it.

Surena F. Matin, MD, of MD Anderson Cancer Center in Houston, asked a panel of urologists focused on UTUC treatment for advice on applying the new AUA/SUO guideline in clinical practice. The panel debated management of real-world patients with low-grade UTUC, and high-grade, high-risk UTUC who had good kidney function.

Dr Matin summarized the take-home messages from the debate in an AUA presentation.

The take-home messages for low-grade UTUC are:

  • Consider mitomycin hydrogel for low-grade recurrent UTUC
  • Use intravesical chemotherapy with nephroureterectomy
  • Consider intravesical chemotherapy after ureteroscopic biopsy, based on anecdotal evidence.

For high-risk UTUC:

  • Risk stratify upper tract tumors
  • Estimate post-nephroureterectomy kidney function to help patients decide between initial surgery or neoadjuvant chemotherapy
  • Consider lymphadenectomy.

The new AUA/SUO guideline follows the release of the European Association of Urology’s 2020 update to its UTUC guideline.


Coleman JA, Clark PE, Bixler BR, et al. Diagnosis and management of non-metastatic upper tract urothelial carcinoma: AUA/SUO guideline. J Urol. 2023;209(6). doi:10.1097/JU.0000000000003480

Coleman JA. Plenary: Friday Afternoon: AUA Guidelines: Upper Tract Urothelial Carcinoma (UTUC). Presented at AUA 2023; April 28, 2023.

Matin S. Friday afternoon: Panel Discussion: Management of Upper Tract Urothelial Carcinoma. Presented at AUA 2023; April 28, 2023.

Managing upper tract urothelial carcinoma in the real world. News release. American Urological Association; April 28, 2023.

This article originally appeared on Renal and Urology News