Low-Grade UTUC Treatment Options for Recurrence After Ablation, Surgery

A roundtable discussion, moderated by Katie S. Murray, DO, MS, discussed the risk stratification and treatment options for low-grade upper tract urothelial carcinoma (UTUC), as well as recent trial data from the 2024 American Urological Association (AUA) Annual Meeting. Dr. Murray was joined by Scot Niglio, MD; Alice Yu, MD; Hong Truong, MD, MS; and Adam Feldman, MD, MPH.

In the fourth segment of the roundtable series, the panel considers how to best treat patients with low-grade UTUC who experience disease recurrence post-ablation and post-surgery.

Watch the next segment in this series.

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Dr. Murray: You hinted at this, but let us pivot a bit. We have been discussing upper tract disease and recurrence rates, and one common concern after ablations is bladder recurrence. Can you shed light on how people consider the bladder’s future when performing any type of ablation on the upper urinary tract or a surgery like nephroureterectomy?

Dr. Yu: Sure. I will start with nephroureterectomy. In my practice, I routinely use intraoperative gemcitabine. I administer gemcitabine at the beginning of the procedure. As we approach the bladder, I drain it, perform a gentle CBI, rinse it out, and then proceed with the cuff to protect the bladder.

Dr. Feldman: I predict that giving gemcitabine at the time of uteroscopy will become standard of care. Though there is not much data now, I believe there will be. Some data supports this, and while I have not started doing it personally, I know colleagues who have, and I plan to. It will likely become an important part of our practice. We administer gemcitabine during TURBT to disperse cells, and we should probably start doing this during uretoroscopy too. Again, no data yet, but it is likely to come. I also use gemcitabine during nephroureterectomy.

And what do you do if there is a bladder tumor along with the upper tract tumor? It is a perfect opportunity to treat both simultaneously. However, it is important to note that you cannot really treat the bladder effectively with the same dose because it is too dilute and diffuses over 4 to 6 hours. So the bladder needs separate treatment.

Dr. Truong: In my practice, whenever I perform ureteroscopy for an upper tract tumor, I always instill gemcitabine in the bladder, whether or not there is a bladder tumor. I explain to the patient that it works by gravity; any circulating cancer cells in the bladder will be affected. This has been shown decisively in bladder literature to prevent recurrence. Before nephroureterectomy, I always perform cystoscopy to ensure there is no bladder tumor. If there is, I take care of it before the bladder cuff is opened to avoid surprises. After the bladder cuff, I position the patient supine and instill gemcitabine in their bladder for an hour, using 2 grams of gemcitabine in 100 ml of normal saline.

Dr. Feldman: So you do a full cystoscopy and lithotomy before the nephroureterectomy?

Dr. Truong: Yes.

Dr. Feldman: And then reposition them?

Dr. Truong: No. I always catheterize before a nephroureterectomy. So before catheterization, I perform flexible cystoscopy.

Dr. Feldman: If you see something, you do a TURBT then?

Dr. Truong: Yes, I do TURBT at the same time if needed. If I perform TURBT, I administer chemotherapy at the end. If there is nothing, I proceed with the bladder cuff and then instill gemcitabine at the end of the case.

Dr. Feldman: So you instill gemcitabine after closing the bladder?

Dr. Truong: That is correct.

Dr. Feldman: Interesting.

Dr. Truong: It is for prevention if there is no tumor in the bladder.

Dr. Feldman: Right. I administer gemcitabine at the start of the case. We put in 2 grams once the catheter is placed. After dividing the hilum and equipping the ureter, we drain the gemcitabine and start continuous bladder irrigation to let it wash in.

Dr. Truong: My rationale is that patients are typically in a lateral position with the cancerous side up, so continuously draining urine keeps any fluid away from that side. I worry that doing it during the case might not allow the chemotherapy to contact the right areas, but it is just a hypothetical concern. I might be overthinking it.

Dr. Murray: That is surgeons for you, always thinking ahead.