Clinical Forum: Advances in low-grade UTUC treatment and care

A recent Urology Times Clinical Forum provided an overview of the complexities in diagnosing and treating low-grade upper tract urothelial carcinoma (UTUC), emphasizing how tumor characteristics and patient health shape clinical decisions. The program was moderated by Katie S. Murray, DO, MS, a professor in the Department of Urology at NYU Grossman School of Medicine and chief of the Urology Service at Bellevue Hospital Center in New York, New York.

This summary was generated by artificial intelligence and edited by humans for clarity.

Katie S. Murray, DO, MS

This Clinical Forum began with an overview of the complexity and nuances involved in diagnosing and treating low-grade UTUC. It highlighted how clinical decisions are often influenced by tumor characteristics such as volume, multifocality, and the patient’s overall health status. Participants acknowledged that guidelines serve primarily as frameworks, and actual practice varies depending on individual clinician experience, available resources, and patient preferences.

A significant portion of the discussion revolved around the importance of accurate diagnosis, including the role of diagnostic tools such as ureteroscopies, biopsies, ureteral cytology, and imaging studies like CT scans. The panelists emphasized that although guidelines recommend biopsies and cytology for risk stratification, these tools have limitations. Biopsies may sometimes be unreliable due to sampling error or insufficient tissue, leading to a potential underestimation of disease severity. Consequently, clinicians often incorporate other assessments such as renal function testing—commonly via renal scans—to evaluate the contralateral kidney’s condition before proceeding with treatment. The importance of considering functional status alongside anatomical findings was underscored, as it influences both the choice of intervention and the likelihood of preserving renal function.

The conversation also touched on risk stratification, which plays a central role in deciding among surgical options. Some clinicians use a formal risk classification system integrating tumor grade, size, multifocality, and cytology results. However, variability exists in how strictly these classifications are applied, often influenced by the clinician’s experience and institutional protocols. For instance, some practitioners rely heavily on biopsy-confirmed low-grade pathology to guide kidney-sparing approaches, trusting their pathology colleagues and the representativeness of biopsy samples. Others pointed out that upstaging can occur postoperatively, particularly if nephroureterectomy becomes necessary due to more aggressive or higher-grade disease discovered later.

A recurring theme was the preference for conservative, kidney-sparing treatments when appropriate. Several practitioners discuss endoscopic management as the primary approach for low-grade disease, especially in cases where tumors are small, unifocal, and accessible via ureteroscopy. Techniques such as ureteroscopic ablation, fulguration, and biopsy were frequently described as effective methods to control the disease while preserving renal function. Participants noted that the ability to treat the entire tumor endoscopically depends on the tumor’s size, location, and extent, with a general consensus that multifocality and high-volume disease may limit this approach. Additionally, intraluminal therapies, including agents such as mitomycin C and gemcitabine, were discussed as adjuncts to endoscopic treatments. The recent introduction of mitomycin reverse thermal hydrogel (Jelmyto) was mentioned as a promising option, providing sustained drug delivery in the upper tract, which could improve outcomes in selected cases.

The panel acknowledged that surveillance plays a key role in managing low-grade UTUC, given the disease’s relatively indolent nature. Regular ureteroscopic examinations, cytology, and imaging are critical for early detection of recurrences or progression. The challenge lies in balancing surveillance intensity with patient adherence and resource availability, particularly because close follow-up involves multiple ureteroscopy sessions over several years.

When discussing surgical intervention, nephroureterectomy with bladder cuff excision remains a definitive treatment, particularly for high-grade or invasive disease. However, for low-grade tumors, participants said they often prefer kidney-sparing approaches to maintain renal function, especially in patients with comorbidities that make radical surgery less desirable. The discussion highlighted that clinicians in academic centers might be more inclined to experiment with conservative management using the latest technology and novel adjuvant therapies, whereas private practitioners emphasize practical constraints and often reserve nephron-saving strategies for carefully selected cases.

In terms of patient cases, the practitioners shared their experiences with real-world cases of patients presenting with low-grade, small, unifocal tumors. One case involved a 62-year-old woman whose disease was diagnosed early through ureteroscopy, with biopsy confirming low-grade pathology. The clinicians chose an endoscopic approach, applying fulguration and intraluminal mitomycin C, with a plan for close surveillance. They stressed that the decision was influenced by tumor characteristics, the patient’s good renal function, and her willingness to adhere to rigorous follow-up. Another case discussed was a patient with multifocal disease, where endoscopic management was considered but ultimately not recommended due to the extent of tumor spread and perceived higher risk for recurrence, leading to nephroureterectomy instead.

Participants also addressed the variability in practice patterns between community urologists and those working in academic centers. Community clinicians tend to favor a more conservative approach centered on ureteroscopic management, relying on biopsy and cytology to guide treatment, whereas academic practitioners may push the boundaries of organ preservation, experimenting with adjunct therapies such as mitomycin reverse thermal hydrogel and employing more aggressive surveillance protocols. This variability underscores the importance of multidisciplinary discussions and tailoring treatment to the individual patient’s disease characteristics and preferences.

Throughout the discussion, the importance of aligning practice with emerging evidence and guidelines was emphasized, recognizing that advancements such as the use of mitomycin reverse thermal hydrogel for low-grade upper tract tumors are reshaping management strategies. The panelists acknowledged that as more data become available, the role of intraluminal chemotherapeutics and thermal gel delivery systems may expand, offering less-invasive options with comparable efficacy for selected patients.

In conclusion, the forum underscored that managing low-grade UTUC remains complex, requiring careful risk assessment, judicious use of diagnostic tools, and a balanced approach between conservative and definitive therapies. Patient education about surveillance and the potential for recurrence or progression is integral to shared decision-making. The discussion reflected a cautious optimism about expanding kidney-sparing options, with emerging therapies such as mitomycin reverse thermal hydrogel playing a promising role. Treatment decisions continue to hinge on tumor-specific factors, patient health, and clinician judgment, aiming to optimize oncologic control while preserving renal function.