Methodology: The study undertakes a comparative analysis of the contemporary guidelines from the EAU and AUA/SUO. Both sets of guidelines were reviewed to identify their recommendations on the diagnosis, evaluation, treatment, and follow-up of UTUC. The analysis focuses on the evidence base, clinical practices, and regional preferences influencing these guidelines.
Diagnosis and Evaluation: Both guidelines recommend cystoscopy and cross-sectional imaging, specifically CT urography, as essential tools for diagnosing UTUC. They emphasize the importance of identifying hereditary risk factors for Lynch syndrome through personal and family history and germline DNA sequencing.
However, the guidelines diverge in some aspects. The AUA/SUO guidelines advocate for retrograde pyelography in patients contraindicated for CT urography, while the EAU guidelines suggest FDG-PET/CT for assessing nodal metastasis in patients unfit for iodinated contrast media.
Risk Stratification: Both guidelines categorize UTUC into low-risk (LR) and high-risk (HR) groups based on tumor grade, cytology, and imaging. The EAU guidelines emphasize pathological subtypes and lymph node involvement as prognostic factors, while the AUA/SUO guidelines provide more detailed sub-stratification within the LR and HR categories to guide risk-adapted management strategies.
Treatment: Conservative Management
Both guidelines favor kidney-sparing surgery for LR UTUC to preserve renal function. Endoscopic ablation is recommended, with follow-up evaluations within three months. The AUA/SUO guidelines provide specific recommendations on energy sources for ablation and the optional use of a ureteral access sheath, which are not detailed in the EAU guidelines.
Surgical Management: For HR UTUC, both guidelines recommend radical nephroureterectomy (NU) with complete bladder cuff excision. They also advise lymph node dissection (LND) during NU for clinically non-metastatic high-risk disease. The EAU guidelines additionally recommend LND to improve cancer-specific survival and reduce local recurrence.
Neoadjuvant and Adjuvant Therapy: Both guidelines support cisplatin-based neoadjuvant chemotherapy (NAC) for HR UTUC. They also recommend adjuvant nivolumab for patients with advanced disease who are ineligible for perioperative cisplatin. The EAU guidelines suggest more detailed criteria for adjuvant chemotherapy based on tumor stage and pathology.
Follow-Up: The guidelines recommend similar follow-up protocols for LR patients post-kidney-sparing treatment, including cystoscopy, upper tract endoscopy, and imaging. For HR patients, the EAU guidelines suggest ureteroscopy and urinary cytology at specific intervals, while the AUA/SUO guidelines recommend more frequent surveillance and imaging.
Conclusions: The comparative analysis reveals substantial agreement between the EAU and AUA/SUO guidelines on the management of UTUC, with notable differences in specific recommendations. These differences highlight the influence of regional practices and resource availability. The findings underscore the importance of ongoing collaboration and harmonization of guidelines to improve UTUC management globally. Future research should focus on bridging the gaps between guidelines to enhance patient outcomes.
Written by: Catalina Solano,1,2 Mariela Corrales,1 Etienne-Xavier Keller,3,4,5 Jia-Lun Kwok,3,6 Frédéric Panthier,1 Steeve Doizi,1 Olivier Traxer1
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, Paris, France.
- Department of Endourology, Uroclin S.A.S., Medellín, Colombia.
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
- Progressive Endourological Association for Research and Leading Solutions (PEARLS), Paris, France.
- Endourology & Urolithiasis Working Group, Young Academic Urologists (YAU), Arnhem, The Netherlands.
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore.
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