Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline

Purpose: The purpose of this guideline is to provide a useful reference on the effective evidence-based diagnoses and management of non-metastatic upper tract urothelial carcinoma (UTUC). Materials/Methods: The Pacific Northwest Evidence-based Practice Center of Oregon Health & Science University (OHSU) team conducted searches in Ovid MEDLINE (1946 to March 3rd, 2022), Cochrane Central Register of Controlled Trials (through January 2022), and Cochrane Database of Systematic Reviews (through January 2022). The searches were updated August 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (Table 1).Table 1. AUA Nomenclature Linking Statement Type to Level of Certainty, Magnitude of Benefit or Risk/Burden, and Body of Evidence Strength Evidence Strength A (High Certainty) Evidence Strength B (Moderate Certainty) Evidence Strength C (Low Certainty) Strong Recommendation(Net benefit or harm substantial) Benefits > Risks/Burdens (or vice versa)Net benefit (or net harm) is substantialApplies to most patients in most circumstances and future research is unlikely to change confidence Benefits > Risks/Burdens (or vice versa)Net benefit (or net harm) is substantialApplies to most patients in most circumstances but better evidence could change confidence Benefits > Risks/Burdens (or vice versa)Net benefit (or net harm) appears substantialApplies to most patients in most circumstances but better evidence is likely to change confidence (Rarely used to support a Strong Recommendation) Moderate Recommendation(Net benefit or harm moderate) Benefits > Risks/Burdens (or vice versa)Net benefit (or net harm) is moderateApplies to most patients in most circumstances and future research is unlikely to change confidence Benefits > Risks/Burdens (or vice versa)Net benefit (or net harm) is moderateApplies to most patients in most circumstances but better evidence could change confidence Benefits > Risks/Burdens (or vice versa)Net benefit (or net harm) appears moderateApplies to most patients in most circumstances but better evidence is likely to change confidence Conditional Recommendation(No apparent net benefit or harm) Benefits = Risks/BurdensBest action depends on individual patient circumstancesFuture research unlikely to change confidence Benefits = Risks/BurdensBest action appears to depend on individual patient circumstancesBetter evidence could change confidence Balance between Benefits & Risks/Burdens unclearAlternative strategies may be equally reasonableBetter evidence likely to change confidence Clinical Principle A statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature Expert Opinion A statement, achieved by consensus of the Panel, that is based on members' clinical training, experience, knowledge, and judgment for which there may or may not be evidence in the medical literature Results: This Guideline provides updated, evidence-based recommendations regarding diagnosis and management of non-metastatic UTUC including risk stratification, surveillance and survivorship. Treatments discussed include kidney sparing management, surgical management, lymph node dissection (LND), neoadjuvant/adjuvant chemotherapy and immunotherapy. Conclusion: This standardized guideline seeks to improve clinicians’ ability to evaluate and treat patients with UTUC based on available evidence. Future studies will be essential to further support these statements for improving patient care. Updates will occur as the knowledge regarding disease biology, clinical behavior and new therapeutic options develop.