Upper urinary tract instillations in the treatment of urothelial carcinomas: a review of technical constraints and outcomes.

OBJECTIVES: The role of topical upper urinary tract instillation as adjuvant treatment after conservative management of urothelial carcinomas remains unclear. The aim of this article was to review available techniques and protocols proposed to treat urothelial carcinomas of the upper tract (UTUC).

METHODS: Evidence acquisition on UTUC topical instillations was performed by a Medline search using combinations of the following key words: urothelial carcinomas; upper urinary tract; renal pelvis; ureter; adjuvant therapy; recurrence; bacillus Calmette-Guérin (BCG); mitomycin C. A total of 36 publications were included in analysis.

RESULTS: Different approaches have been reported for instillation of the upper tract (UT): percutaneous nephrostomy, retrograde catheterisation and vesico-ureteral reflux. Currently, BCG and mitomycin C are the most commonly agents used for topical treatment of UTUC. A role for BCG in the management of UT carcinoma in situ (CIS) has been demonstrated in retrospective studies, although a definitive efficacy of adjuvant topical therapy after endoscopic resection of Ta/T1 tumours has not yet been proven. No individual study has shown a statistical improvement in survival and recurrence rates.

CONCLUSION: Currently BCG instillation should be considered as first-line treatment for UT CIS managed conservatively in carefully selected patients. The place for adjuvant topical instillation after ablation of Ta/T1 tumours is less evident and should be evaluated on an individual basis.