Treating Localised Upper Tract Urothelial Cancer

When UTUC has not spread beyond the kidney and ureter, the aim of treatment is to remove or destroy it completely. The right approach depends above all on the grade of the cancer (low grade or high grade) and its size and position, as well as your kidney function and general health. This is a shared decision, and the choice balances controlling the cancer against preserving as much kidney function as possible.

For some tumours, it is possible to treat the cancer without removing the kidney. This protects kidney function and is preferred when it can be done safely.

Endoscopic (ureteroscopic) treatment. Using the same thin, flexible telescope employed to make the diagnosis (a ureteroscope), a small tumour can be destroyed in place with a laser, passed up through the ureter — with no cuts in the skin. This is best suited to small, low-grade, surface tumours (generally low-grade Ta tumours under 2 cm). It is not suitable for high-grade tumours, which behave more aggressively and need more definitive treatment. Because these tumours can come back, endoscopic treatment is followed by regular monitoring with repeat ureteroscopy, and further treatment if needed.

Distal ureterectomy. When the tumour is in the lower part of the ureter — particularly a bulkier low-grade tumour — it may be possible to remove just that segment of the ureter and rejoin the remainder to the bladder, rather than removing the whole kidney and ureter. This spares the kidney while still removing the affected passage. A robot-assisted approach is preferred: the lower ureter sits deep in the pelvis, so the robotic platform gives better visualisation in this confined area, along with less blood loss and a faster recovery than open surgery.

For high-grade tumours, and for large low-grade surface (Ta) tumours, the standard treatment is to remove the whole kidney, the ureter, and a small cuff of the bladder where the ureter joins it — an operation called nephroureterectomy. Removing the entire drainage passage matters, because urothelial cancer can otherwise recur along it.

Large low-grade tumours are treated this way because a tumour that looks mostly low grade can contain hidden higher-grade areas that the small biopsy samples may have missed, which can make kidney-sparing options unsafe. Wherever possible, nephroureterectomy is performed using a robot-assisted approach, which allows the operation to be carried out precisely through small incisions, with less blood loss and a quicker recovery than open surgery. People who start with good kidney function generally manage well with one kidney afterwards.

At the time of surgery, a single dose of chemotherapy is usually placed into the bladder. This is not to treat the upper tract tumour itself, but to lower the chance of a new tumour appearing in the bladder afterwards — a recognised risk, because the bladder shares the same lining. It is a simple, well-tolerated addition given around the time of the operation.

For some higher-risk UTUCs, drug treatment is given as well as surgery, to lower the chance of the cancer returning. The POUT trial showed that chemotherapy given after nephroureterectomy improves the chance of staying free of cancer. More recently, the CheckMate 274 and AMBASSADOR trials — which included upper tract cancers — showed a benefit from immunotherapy after surgery. Some patients may also benefit from drug treatment before surgery, depending on the cancer’s stage and their kidney function. The timing and type of treatment is tailored to you, and your team will discuss which approach suits you best.

When UTUC is more advanced, treatment often begins with drug therapy, and surgery to remove the kidney and ureter may then be considered if the cancer responds well and you remain fit. This is a selective, case-by-case decision made with your team.