Upper urinary tract recurrence following bladder cancer therapy: a review of surveillance and management

Our aim is to review recent investigations into the recurrence of urothelial carcinoma in the upper urinary tract following bladder cancer therapy focusing on surveillance and management.After radical cystectomy, rates of recurrence in the upper tract are between 0.75 and 6.4%. The poor prognosis of upper tract urothelial carcinoma (UTUC) is in part attributable to delayed diagnosis. Guidelines recommend a gradual de-escalation of surveillance in disease-free patients with the potential for discontinuation beyond 5 years. Previous guideline audits have shown that recurrences are still missed, suggesting a need for longer follow-up. Studies propose risk stratifying patients by age, comorbidities, and tumor stage to warrant closer surveillance and identify adjuvant therapy candidates. Larger studies are needed to advise treatment of UTUC after a urothelial bladder cancer (UBC) diagnosis, as these patients face poorer outcomes following radical nephroureterectomy. Clinical trials have demonstrated the efficacy of neoadjuvant and adjuvant systemic therapy after radical nephroureterectomy for primary UTUC; however, the literature is lacking robust data on patients who develop urothelial carcinoma in the upper tract following an initial UBC diagnosis.Many asymptomatic recurrences of urothelial carcinoma in the upper tract are undetected by current surveillance guideline recommendations. Higher level evidence is needed to confirm the efficacy of prolonged and risk-adapted surveillance of patients with UBC and the extirpative management of recurrence in the upper tract after UBC treatment.