UGN-101 as an Alternative Treatment Approach to Surgery for Low-Grade UTUC

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 fifth segment of the roundtable series, the panel transitions to non-surgical approaches to treatment for low-grade UTUC, including UGN-101. Together, they dissect a longitudinal follow-up of a multicenter study of UGN-101 as well as other 2024 AUA Annual Meeting data.

Watch the next segment in this series.

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Dr. Murray: Let us focus on UGN-101, which Dr. Feldman has mentioned several times. It is being used as an alternative to endoscopic ablations and as its own chemoablation. Exciting new data is coming out, hopefully to be published soon after AUA. Dr. Feldman, could you tell us more about that?

Dr. Feldman: Sure. Let us talk about the efficacy of UGN-101. Based on the OLYMPUS trial, 58% of patients had a complete response after induction, and of those, about 56% remained disease-free at 1 year. In real-world experience, we have seen just under half of patients have a complete response after induction. Of those, 68% have remained recurrence-free at 3 years, which is quite promising.

One thing we have noticed is that tumor multifocality, size, and administration route did not correlate with recurrence. Interestingly, maintenance likely helps reduce the risk of recurrence.

Another important point is in higher-volume disease, downsizing and partial ablation are still beneficial. Patients who had residual disease and underwent re-look ureteroscopy showed about 60% becoming disease-free after laser ablation. We do not have long-term data on this group yet, but it is a positive outcome for many patients.

Dr. Murray: And it is important to select appropriate patients for these treatments. Dr. Yu, as someone early in your career, with all this new data emerging, does it change your perspective on future practice?

Dr. Yu: Absolutely. It is crucial to stay updated on evolving data in oncology and urology. New findings can significantly impact our practice, and being open to change is essential.

I have a question about the administration route. What is the most common approach in your experience?

Dr. Murray: Dr. Feldman and I have administered it differently. I have primarily used the antegrade approach, collaborating with medical oncology for instilling UGN-101. In real-world data, it is about 50/50.

Dr. Feldman: Yes, about 50/50. I offer both approaches and discuss the risks and benefits with patients. If you do not have fluoroscopy, antegrade is easier. For retrograde, you need fluoroscopy and may need to replace the ureteral catheter.

It is important to be gentle during catheter insertion to avoid ureteral stenosis. If there are concerns, we take a break. Some debate surrounds the use of oral steroids in this regard.

Dr. Murray: Have you used UGN-101 on any patients?

Dr. Yu: Yes, at our center, we use the antegrade approach in our infusion center.

Dr. Truong: Do you give UGN-101 to patients with ureteral tumors?

Dr. Feldman: Yes, we have seen responses in ureteral tumors. Even patients with stents have responded, as the medication can reach around the stent.

Dr. Truong: Have you noticed an increased risk of upper stricture with ureteral tumors?

Dr. Feldman: No, the presence of ureteral tumors does not seem to increase the risk of stricture.

Dr. Murray: That is correct. It is important to be cautious during laser treatment to avoid circumferential lasering, particularly in patients with ureteral tumors.

Dr. Feldman: For low-grade distal ureteral tumors, especially if it is not endoscopically manageable, a distal ureterectomy and re-implantation may be the best approach to avoid risking the entire ureter.

Dr. Truong: Agreed. I typically opt for distal ureterectomy for these cases, regardless of grade, followed by pelvic lymph node dissection for high-grade tumors.

Dr. Feldman: And then cystoscopy and ureteroscopy in the office through the anastomosis.

Dr. Murray: Exactly.