Organ-sparing treatment in synchronous bilateral upper tract urothelial carcinoma and bladder cancer

Introduction. Upper tract urothelial carcinoma (UTUC) is a rare but aggressive malignancy associated with high rates of recurrence, diagnostic and staging challenges, and a substantial risk of implantation metastasis. In patients with bilateral or multifocal disease, standard radical nephroureterectomy results in loss of renal function, thereby limiting options for systemic therapy and adversely affecting quality of life. Current clinical guidelines increasingly support organ-preserving endoscopic approaches in carefully selected patients. We present a case illustrating successful stepwise organ-preserving management (laser excision, neoadjuvant chemotherapy, nephroureterectomy, and adjuvant immunotherapy) in a patient with metachronous primary multifocal urothelial carcinoma.
Case presentation. A 62-year-old man with a long history of non–muscle-invasive bladder cancer and recurrent disease despite multiple transurethral resections and intravesical therapy was found to have bilateral upper urinary tract involvement. He underwent ureteropyeloscopy with laser multifocal excision of tumors from the left renal pelvis and left ureter (Ta, low grade) and transurethral resection of the bladder. Four cycles of neoadjuvant chemotherapy with gemcitabine and cisplatin were administered for invasive urothelial carcinoma of the right renal pelvis (cT2N0M0). A partial response was achieved according to RECIST v1.1 (tumor size reduction 39–58%). Subsequently, laparoscopic right nephroureterectomy with paracaval lymphadenectomy and resection of the right ureteral orifice was performed. Histopathological examination revealed invasive high-grade urothelial carcinoma pT2N0, tumor regression grade 3 (indicating a poor response to neoadjuvant chemotherapy). The estimated glomerular filtration rate after completion of all procedures decreased to 58 mL/min/1.73 m². Adjuvant immunotherapy with nivolumab was initiated.
Conclusion. This case demonstrates that, even in the setting of an incomplete pathomorphological response to neoadjuvant chemotherapy, a comprehensive strategy that preserves the function of the remaining kidney can achieve oncologic radicality, enable adjuvant immunotherapy, and prevent dialysis dependence. Organ-preserving interventions for UTUC should be considered in specialized centers within a multidisciplinary framework.

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