Surgical management of high-risk upper tract urothelial carcinoma

The definition of high-risk UTUC comprises the risk of progression, and not merely the risk of intracavitary recurrence. In this respect, open radical nephroureterectomy is the standard treatment for high-risk UTUC, which consists of the removal of the entire kidney and ureter along with excision of the bladder cuff. Laparoscopic approaches have been shown to provide similar outcomes in terms of lymph node yield and completeness of resection, but these techniques have to be considered investigational. Kidney-sparing surgery for the management of high-risk UTUC is an acceptable alternative to RNU in selected patients with elective or imperative indications. Close and lifelong surveillance of the remaining urothelium is mandatory in all patients undergoing kidney-sparing surgery for high-risk UTUC. Adjuvant intracavitary instillation of BCG is an effective option in patients with pure or concomitant CIS of the upper tract while its benefit remains questionable in Ta-T1 disease. Perioperative single-dose intravesical chemotherapy following RNU has shown to reduce the risk of intravesical recurrence following RNU. Increasing evidence suggests a prognostic role of regional lymph node dissection during RNU as the presence of positive nodes is associated with an increased risk of recurrence. However, its extent has not been investigated in depth so far.