Upper tract surveillance of patients with high-risk non-muscle invasive bladder cancer: A risk-stratified approach for detecting upper tract urothelial carcinoma recurrence based on long-term follow-up data

Objective: To propose a surveillance approach for upper tract urothelial carcinoma (UTUC) recurrence in high-risk and very high-risk non-muscle invasive bladder cancer (HR NMIBC) patients. Method: Retrospective analysis in 2024 of 317 patients diagnosed with HR NMIBC in our centre between 2008 and 2018, including histology, CT urogram (CTU) frequency, radiation dose, UTUC recurrence, outcome, and risk factors for UTUC recurrence. Results: A total of 283 patients were included for analysis. Incidence of UTUC recurrence 5.7% ( n = 16/283), with 3.5% ( n = 10/283) undergoing nephroureterectomy. Mean time from initial diagnosis to UTUC recurrence is 5.2 years. At 5- and 10-year follow-up, UTUC incidence was 3.5% and 2.1%, respectively. No patients diagnosed with UTUC recurrence beyond 10 years. Patients underwent mean 2.2 surveillance CTU every 1.9 years, with 17.7 mSv mean radiation dose per scan. No significant increased risk of UTUC recurrence associated with carcinoma in situ (CIS) at diagnosis (χ 2 = 0.006, p value = 0.94). Risk of UTUC recurrence significantly increased in patients with recurrent HR NMIBC (27%) versus those without (4%) (relative risk = 7.12, χ 2 = 20.9, p value < 0.00001). Conclusion: Consider surgical fitness and HR NMIBC recurrence status when determining duration of surveillance for patients. We propose biennial CTU in patients fit for nephroureterectomy, continuing up to 10 years if recurrent HR NMIBC, or up to 5 years if recurrence-free. Level of evidence: 2b – Retrospective cohort study