Prognosis
5-year overall survival:
| By grade | Survival | By stage | Survival |
|---|---|---|---|
| Grade 1–2 | 40–87% | Ta/T1/CIS | 60–90% |
| Grade 3–4 | 0–33% | T2 | 43–75% |
| T3 | 16–33% | ||
| T4 | 0–5% | ||
| N+ | 0–4% | ||
| M+ | 0% |
Prognostic factors:
- Stage — the most important factor; non–organ-confined disease (>pT2) is the strongest predictor of metastasis.
- Grade — high-grade tumours invade more and associate with CIS; stage and grade each independently predict recurrence.
- Architecture — ~85% of renal pelvic tumours are papillary; papillary lesions do better than sessile (invasion occurs in 50% of papillary vs >80% of sessile tumours).
- CIS — higher progression risk.
- Size — >3–4 cm may worsen survival and bladder-recurrence risk.
- Location — renal pelvic tumours are usually more aggressive (50–60% invasive) than ureteral; the renal parenchyma may slow spread of T3 pelvic tumours, whereas periureteral extension disseminates early (evidence is conflicting overall).
- Multifocality — ≥2 urothelial sites; an independent predictor of poor outcome.
- Lymph node involvement, lymphovascular invasion (worse in node-negative disease), hydronephrosis, positive margins, and prior/concomitant bladder tumours.
- Patient/surgical factors — increasing age, Black non-Hispanic race, and lack of post-op MMC instillation. The aristolochic-acid, analgesic-abuse, and Lynch-associated forms have a higher tendency to multiple/bilateral recurrence.
Surveillance
Surveillance aims to detect urothelial recurrences, de novo urinary-tract tumours, and regional/distant metastases early. After nephron-sparing surgery most patients develop ipsilateral upper-tract recurrence (proximal-to-distal field change, more pronounced than in the bladder).
- Intravesical recurrence — ~30% develop bladder cancer after RNU or nephron-sparing surgery, mostly within 2 years (median 6–12 months). Risk factors include male sex, previous bladder cancer, preoperative CKD, positive preoperative cytology, ureteral tumour size, multifocality, invasive T-stage, necrosis, laparoscopic approach, extravesical bladder-cuff removal, positive margins, and prior ureteroscopic biopsy.
- Contralateral recurrence — ~2%.
- Distant metastasis — ~16% after RNU (median 13–16 months): lung 5%, bone 4%, liver 4%; brain rare (image promptly for neurologic symptoms).
Post-operative evaluation routinely includes cystoscopy (bladder), upper-tract endoscopy and imaging (CT urography preferred; MR urography/retrograde if contrast contraindicated) of the ipsilateral (if organ-sparing) and contralateral tracts, urine cytology, and chest imaging (CXR or CT).
AUA schedule (abbreviated):
- After kidney-sparing, low-risk — cystoscopy + upper-tract endoscopy at 1–3 months to confirm treatment; then cystoscopy within the first year and ≥6–9 monthly for 2 years then annually; upper-tract endoscopy at 6 and 12 months; upper-tract imaging ≥6–9 monthly for 2 years then annually to 5 years; no distant evaluation.
- After kidney-sparing, high-risk — as above plus cytology, with cystoscopy/cytology every 3–6 months for 3 years then 6–12 monthly to 5 years, upper-tract imaging + BMP every 3–6 months for 3 years, and chest imaging every 6–12 months to 5 years.
- After RNU, <pT2 N0/M0 — cystoscopy + cytology at 3 months then by grade (LG ≥5–9 monthly ×2 years then annually; HG every 3–6 months ×3 years then annually); abdomen/pelvis imaging within 6 months then annually ≥5 years (~5% contralateral risk).
- After RNU, T2+ — cystoscopy + cytology at 3 months then every 3–6 months ×3 years then annually; contrast CT urography of abdomen/pelvis every 3–6 months years 1–2, every 6 months year 3, then annually to 5; chest CT every 6–12 months for 5 years.
CUA schedule — cytology + cystoscopy at months 3, 6, 12, 18, 24 then annually to 10 years; ipsilateral upper tract by URS + selective cytology/biopsy on the same schedule after nephron-sparing surgery; abdomen/pelvis CT urography, CXR, and bone scan (if indicated) for distant sites. High-grade/pT≥2/pN+ warrant lifelong annual surveillance; low-grade pT<2 may be discharged after 10 recurrence-free years.
Sequelae of nephroureterectomy — reassess blood pressure, eGFR, and proteinuria soon after surgery and at 3–6 months for CKD development/progression (hyperfiltration can damage remaining nephrons). Optimize diabetes/hypertension control and smoking cessation, avoid nephrotoxins, and refer to nephrology for progressive insufficiency or proteinuria. Survivorship — encourage smoking cessation, exercise, and a healthy diet; UTUC associates with metabolic syndrome and obesity, which worsen outcomes.
Self-Test
1. What is the most important predictor of developing metastasis in UTUC? T stage >2 (non–organ-confined disease).
2. What is the most important prognostic factor for survival in UTUC? Stage (note: in NMIBC, grade has a stronger association with progression than stage).
3. After nephroureterectomy, what is the risk of intravesical recurrence and of contralateral upper-tract recurrence? ~30% intravesical recurrence (mostly within 2 years) and ~2% contralateral upper-tract recurrence.