Diagnosis and treatment of urothelial carcinoma of the upper urinary tract: Evaluation of guideline compliance 2011-2024.

Abstract

Background: Urothelial carcinoma of the upper urinary tract (UTUC) requires a complex, multimodal treatment approach. The European Association of Urology (EAU) publishes evidence-based guidelines on the diagnosis and treatment of this rare tumour every year. However, due to the low number of cases and diagnostic challenges, their implementation in everyday clinical practice is often difficult. The objective of this retrospective analysis was to evaluate guideline-compliant care for patients diagnosed with UTUC and to investigate potential associations between non-guideline therapy decisions and overall survival and other oncological outcomes.

Methods: The study included 181 patients diagnosed with UTUC who were treated at our clinic between 2011 and 2024. Treatment courses and oncological outcomes were analyzed based on EAU guidelines, and the overall course was examined in relation to treatment adherence.

Results: 13% (n=25) of patients received diagnostics or therapy that did not comply with guidelines. The main causes were a lack of resection of the bladder cuff (n=13; 52%), the absence of adjuvant chemotherapy (n=8, 32% 2020 - 2024), the absence of an interdisciplinary case discussion in the form of a tumour board (n=3; 17%), and inadequate surgical treatment (n=1; 5%). In unadjusted analyses, omission of bladder cuff resection was associated with poorer overall survival (p=0.047) and a higher recurrence rate (p=0.038), while the association with overall survival was no longer statistically significant in an exploratory analysis adjusted for age and pathological tumour stage (HR 0.57, 95% CI 0.25-1.30; p=0.183). In addition, diagnostics, the interpretation of CT, cytology and URS biopsy results for the correct classification of low-risk and high-risk patients, and the administration of adjuvant chemotherapy repeatedly showed deviations from the guideline-based criteria for risk stratification.

Conclusion: Despite clear recommendations from the EAU, consistent implementation in everyday clinical practice remains a challenge. In addition to the rarity of the condition, challenging diagnostic pathways contribute to its limited use. However, guideline-compliant care may be of clinical importance, as deviations could be associated with poorer oncological outcomes.