Kidney Sparing in UTUC: The Right Patients and Optimal Techniques

Surena F. Matin, MD, The University of Texas MD Anderson Cancer Center, and David Ambinder, MD, Urology Resident, New York Medical College/Westchester Medical Center, break down kidney-sparing management for UTUC, who the ideal patients may be for kidney sparing, and the conventional standard of care for patients who undergo either a complete endoscopic resection or a minimal ureter resection.

Dr. Ambinder: Who are the ideal candidates for kidney-sparing procedures?

Dr. Matin: According to the European guidelines, the ideal candidates can be classified as low-risk or high-risk. From my perspective, the low-risk category includes patients with a single tumor less than 2 centimeters (or 1.5 centimeters) and no indication of high grade. These cases are particularly gratifying for urologists as they can be treated with ureteroscopy, obtaining the whole tumor with 1 biopsy or basket and laser ablation. The AUA guidelines also define a favorable low-risk category. These patients are the most ideal candidates for kidney preservation in an elective setting.

However, none of these guidelines accurately predict the risk of recurrence, which is the Achilles’ heel of kidney preservation. Some cases never recur after treatment, while others initially appear successful but later present with widespread recurrence. Predicting this outcome is challenging. Nevertheless, we have a sense of who might be good initial candidates for kidney-sparing procedures. The complexity arises in urgent situations where the patient has a solitary kidney, chronic kidney disease, or indications of high grade. In such cases, it becomes difficult to determine if kidney preservation is the most appropriate approach.

Dr. Ambinder: It’s a challenging task to identify those patients. Before we delve into the OLYMPUS trial, which is significant, what was the standard procedure for patients who underwent complete endoscopic resection or minimal ureter resection?

Dr. Matin: Truthfully, there was no standardized approach in those scenarios. Ureterectomy was considered the gold standard, while other methods were somewhat uncharted territory. Many physicians employed topical therapy in various ways, including ourselves. However, those of us who performed these procedures frequently recognized the importance of reliably delivering the medication.

Simply relying on stents and hoping for bladder reflux, for example, was not dependable. The only reliable methods involved the use of tubes inserted either antegrade or retrograde to ensure accurate delivery. Since the urinary tract is not a reservoir organ, the medication had to be administered slowly through these tubes. It was a basic approach to the situation.

Additionally, different medications were used. Notably, data from Switzerland showed reasonable outcomes with BCG installations for patients with CIS, but the results were less favorable for preventing recurrence of papillary disease. This led me to consider the role of the immune system, although this was before the emergence of checkpoint inhibitors and the discussion on the tumor immune microenvironment. With that data in mind, I decided to use chemo, primarily mitomycin, at that time. Although I wasn’t fond of mitomycin due to its finicky nature and the challenges associated with optimizing its administration conditions, we utilized topical therapy for a period.

The introduction of mitomycin hydrogel played a significant role in establishing a standardized approach. Regardless of personal beliefs or preferences, the study represented a culmination of years of conversations with urologists and the FDA. It can be viewed as a consensus among experts in the field.

View their other comments on Staging and Therapeutic Considerations of Lymphadenectomy for UTUC and the OLYMPUS trial for Patients With Low-Grade UTUC.