Page 1 - Guidelines for postoperative surveillance of upper urinary tract urothelial carcinoma

CUA GUIDELINE

Canadian guidelines for postoperative surveillance of upper urinary

tract urothelial carcinoma

Anil Kapoor, MD, FRCSC; Christopher B. Allard, MD; Peter Black, MD, FRCSC; Wassim Kassouf, MD, FRCSC;
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Christopher Morash, MD, FRCSC; Ricardo Rendon, MD, FRCSC
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* Division of Urology, McMaster University, Hamilton, ON; Department of Urologic Science, University of British Columbia, Vancouver, BC; Department of Surgery (Urology), McGill University, Montreal,
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QC; Department of Surgery, Division of Urology, University of Ottawa, Ottawa, ON; Department of Urology, Dalhousie University, Halifax, NS
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Cite as: Can Urol Assoc J 2013;7(9-10):306-11. http://dx.doi.org/10.5489/cuaj.1578 transitional cell carcinoma, nephrouretectomy, ureterec-
Published online October 7, 2013. tomy, endoscopy, ureteroscopy, nephroscopy, percuta-
neous, follow-up, surveillance, recurrence, outcomes and
prognosis. No language restrictions were implemented.
Introduction Citations from included articles and review articles were
manually searched.
Upper urinary tract urothelial carcinoma (UTUC) is a rare The inclusion and exclusion criteria were defined a priori.
malignancy, accounting for 5% of urothelial tumours. The We included studies which reported rates and/or patterns of
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gold standard management for non-metastatic UTUC is rad- recurrence after surgery (nephroureterectomy or nephron-
ical nephrouretectomy with bladder cuff excision. Nephron- sparing procedures) for UTUC. Nephron-sparing procedures
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sparing procedures, including segmental ureterectomy and include segmental ureterectomy and endoscopic (retrograde
endoscopic ablation or resection, are often employed in or antegrade) ablation or resection. Non-observational stud-
select patients. Postoperative recurrences are common. The ies were excluded. No sample size limitations were applied
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primary aims of postoperative surveillance for UTUC are to to prospective studies. For retrospective studies, minimum
identify urothelial recurrences, de novo tumours of the urin- sample sizes for nephroureterectomy series and nephron-
ary tract, and distant metastases at early stages when they sparing series were 100 and 20 respectively, with exceptions
may be amenable to treatment. The rarity of the disease, as for special reasons by author consensus and with explana-
well as the heterogeneity of treatments, complicates the task tion. When multiple studies reporting on the same patient
of developing a standard follow-up protocol. population were identified, we attempted to include only
Multiple studies report on postoperative recurrence and the most relevant study. Studies with major design flaws
prognosis for UTUC. By performing a systematic literature were excluded by author consensus and with explanation.
review, we generated an evidence-based consensus proto- For recurrence/metastases rates, weighted means across all
col for the surveillance of patients after surgery for UTUC relevant studies were calculated when possible; these are
based on the predictors, timing and locations of recur - reported as “mean (range of means).” Where applicable,
rences reported in the literature. The decision to provide the weighted mean of follow-up duration is also included
neoadjuvant or adjuvant treatments is beyond the scope of within parentheses.
this guideline and will not be reviewed. Wherever possible,
the levels of evidence and grades of recommendation are Results
noted using the modified Oxford Centre for Evidence-based
Medicine system. In total, 59 studies satisfied the inclusion criteria, of which
33 pertained to nephroureterectomy 4-36 and 26 to nephron-
Methods sparing procedures (Fig. 1). 37-62 One prospective study was
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included; the rest are retrospective case-series, including
A systematic literature review of the electronic databases several large multicentre series. One retrospective study of
Embase, Medline and Cochrane was performed using the patients after nephroureterectomy with a sample size <100
following search terms, their synonyms, related terms and was included by author consensus because of its large sam-
relevant exploded terms: upper tract, urothelial carcinoma, ple of pT3 tumours. No studies were excluded for major
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306 CUAJ • September-October 2013 • Volume 7, Issues 9-10
© 2013 Canadian Urological Association