Nephroureterectomy and Jelmyto for Upper Tract Urothelial Cancer (UTUC)
Upper tract urothelial cancer (UTUC) is urothelial cancer that grows in the lining of the renal pelvis or ureter, the same type of cancer that occurs in the bladder, but located in the upper urinary tract. Treatment depends on grade, stage, location, kidney function, and whether the tumor can be safely managed without removing the kidney. Options range from kidney-sparing endoscopic resection and Jelmyto (intra-renal pelvis mitomycin) to formal robotic nephroureterectomy with bladder cuff excision.
Dr. Wei Phin Tan offers the full spectrum of UTUC management at NYU Langone Health, Main Campus in Manhattan, including robotic nephroureterectomy with bladder cuff excision, endoscopic laser ablation, and Jelmyto (mitomycin pyelocalyceal solution) for selected low-grade UTUC.
"For the right patient with low-grade UTUC, we can treat the cancer and keep the kidney. For high-grade or invasive disease, removing the kidney and ureter together is still the safest oncologic answer. The decision starts with imaging, ureteroscopy, and biopsy, not assumptions."- Dr. Wei Phin Tan, MD, MHS, FACS
How UTUC Is Diagnosed
- CT urogram to identify a filling defect, mass, or hydronephrosis in the renal pelvis or ureter
- Diagnostic ureteroscopy with the flexible ureteroscope to visualize and biopsy the lesion
- Selective urine cytology from the upper tract
- Cystoscopy to rule out concurrent bladder tumors
- Cross-sectional imaging for staging when high-grade disease is suspected
Grade and stage from this workup decide whether the tumor can be managed with kidney-sparing therapy or whether nephroureterectomy is the safer choice.
Treatment Pathways
| Scenario | Preferred treatment | Alternative considerations |
|---|---|---|
| Low-grade, low-volume, single-kidney or solitary kidney | Endoscopic laser ablation ± Jelmyto | Selective surveillance in carefully chosen cases |
| Low-grade UTUC with normal contralateral kidney | Endoscopic laser ablation ± Jelmyto, or nephroureterectomy | Decision based on volume, location, kidney function |
| High-grade UTUC, any size | Robotic nephroureterectomy with bladder cuff excision | Neoadjuvant cisplatin-based chemotherapy in selected patients |
| Invasive (cT2+) or large/multifocal high-grade | Neoadjuvant chemotherapy + nephroureterectomy | Extended lymph node dissection at the time of surgery |
Treatment is highly individualized. Final decisions are based on imaging, ureteroscopy findings, biopsy grade, kidney function, and patient preference.
Robotic Nephroureterectomy with Bladder Cuff Excision
Robotic nephroureterectomy is the standard surgical treatment for high-risk UTUC. Through small port-site incisions, Dr. Tan removes the entire kidney and the entire ureter, including a cuff of the bladder where the ureter enters. Removing the bladder cuff is essential because UTUC has a high rate of recurrence at the ureteral stump if any ureteral tissue is left behind. Lymph node dissection is performed when oncologically indicated.
- Robotic approach with small port-site incisions, lower blood loss, and faster recovery than open nephroureterectomy
- Bladder cuff excision performed with a watertight bladder closure to prevent tumor seeding
- Single-dose post-operative intravesical chemotherapy (mitomycin or gemcitabine) within 10 days, which reduces the rate of subsequent bladder recurrence
- Surveillance cystoscopy in the months and years that follow, since 30 to 50 percent of patients develop new bladder tumors after UTUC
Kidney-Sparing Endoscopic Management
For carefully selected patients with low-grade, low-volume UTUC, the cancer can be treated through the ureteroscope using laser ablation (most commonly Holmium or Thulium laser). Patients with a single kidney, baseline kidney dysfunction, bilateral disease, or strong patient preference for kidney preservation are particularly considered. Endoscopic management requires close surveillance with repeat ureteroscopy.
Jelmyto (Mitomycin Pyelocalyceal Solution)
Jelmyto is a mitomycin reverse-thermal hydrogel developed by UroGen and FDA-approved for low-grade UTUC. The medication is liquid at room temperature, gels at body temperature, and is instilled into the renal pelvis through a ureteral catheter. The gel coats the upper tract for 4 to 6 hours, releasing mitomycin as it dissolves, and then passes in the urine. It is delivered weekly for 6 weeks of induction, with maintenance dosing in selected patients.
- FDA-approved indication: low-grade non-invasive UTUC
- Common candidate scenarios: a small low-grade tumor incompletely treatable endoscopically, recurrent low-grade disease after endoscopic ablation, or patients who want to avoid nephroureterectomy
- Side effects: ureteral stenosis (most common), urinary tract infection, hematuria, and flank pain
- Not appropriate for: high-grade UTUC, invasive disease, or large-volume tumor where complete coating cannot be achieved
Surveillance After UTUC Treatment
- Cystoscopy every 3 months in the first year, then less frequent based on findings
- Surveillance imaging of the contralateral upper tract (CT urogram, retrograde pyelogram) at intervals based on risk
- Urine cytology for high-grade disease
- Repeat ureteroscopy after endoscopic management or Jelmyto, particularly during the first 1 to 2 years
- Long-term monitoring of kidney function, particularly after nephroureterectomy in patients with comorbid kidney disease
Selected Evidence (Dr. Tan's Published Work)
Dr. Tan has published on nephroureterectomy technique and surgical controversies, urinary biomarkers in upper tract urothelial cancer recurrence, and timing of surgery for urothelial cancer:
- Barton GJ, Tan WP, Inman BA. The nephroureterectomy: review of technique and current controversies. Translational Andrology and Urology. 2020. PMID 33457289
- Tan WP, Tecle N, Whelan P, et al. Upper tract urothelial carcinoma: urinary markers in predicting recurrence. Journal of Endourology Case Reports. 2016. PMID 28078326
- Leow JJ, Tan WS, Tan WP, et al. Delaying surgery for urothelial carcinoma: systematic review and meta-analysis. Frontiers in Surgery. 2022. PMID 36268209
Full publication list pulled live from PubMed on the Publications page.