Role of Chemotherapy and Immunotherapy for Urinary Upper Tract Cancer

Background and objectiveThe gold standard for open radical nephroureterectomy is currently being challenged by minimally invasive procedures for upper tract tumour management. A nephron-sparing approach may be proposed in patients with an anatomic or functionally solitary kidney, bilateral disease, significant chronic renal insufficiency, or medical comorbidities in whom major surgical procedure would be poorly tolerated.Material, methods and resultsLocal recurrence has been observed in 65% of patients with endoscopically treated upper tract tumours, with an average time to recurrence of <10 mo. Adjuvant topical immunotherapy or chemotherapy agents have been reported in the literature for treatment and prophylaxis of transitional cell carcinoma. Two major techniques are usually recommended for the administration of mitomycin C (MMC) and bacillus Calmette-Guérin (BCG): perfusion through a percutaneous nephrostomy tube or by retrograde reflux from the bladder with an indwelling double-J stent in the Trendelenburg position. BCG therapy has been reported to provide cure in approximately 50% of renal units with carcinoma in situ; however, papillary and solid tumour recurrences of the urinary upper tract cannot be prevented with BCG therapy. Adjuvant therapy is considered safe, with no systemic side-effects resulting from perfusion with MMC as topical therapy following endoscopic resection of upper urinary tract carcinoma. In contrast, up to 25% of patients may have granulomatous involvement of the urinary tract after BCG administration.ConclusionThe efficacy and safety of this conservative approach warrants further evaluation, as long-term follow-up is necessary to confirm previously reported oncologic data. Moreover, adjuvant therapy may be proposed with the patient's consent, as it requires a strict ureteroscopic surveillance protocol.