Technological advances and the evolution of endoscopic procedures in the treatment of upper urinary tract tumors: clinical impact and future perspectives

Abstract

Background: Upper tract urothelial carcinoma (UTUC) is a rare malignancy, accounting for 5-10% of urothelial cancers, and is traditionally managed with radical nephroureterectomy (RNU). Although RNU offers effective oncological control, it is associated with significant morbidity, including chronic kidney disease and cardiovascular complications. Recent advancements in endoscopic technology have enabled minimally invasive approaches, particularly for low-risk tumors, emphasizing kidney preservation and reducing treatment-related morbidity. Methods: This review conducted a comprehensive literature search across PubMed, Scopus, Google Scholar, and Web of Science, focusing on studies published from 2020 to 2024. Keywords included “endoscopic treatment,” “upper urinary tract tumors,” “ureteroscopy,” “laser technologies,” and “renal preservation.” Eligible studies were screened based on relevance, methodological quality, and direct focus on endoscopic management of UTUC. The review discusses technological innovations, oncological outcomes, and associated challenges. Results: Endoscopic management, particularly flexible ureteroscopy and laser technologies, has emerged as a viable alternative to RNU for selected low-risk UTUC cases. Techniques such as holmium and thulium laser ablation allow precise tumor resection with minimal thermal damage, while advanced imaging methods, including Narrow Band Imaging (NBI) and Photodynamic Diagnosis (PDD), enhance tumor visualization and resection accuracy. Intraluminal therapies, such as gel-based mitomycin and Bacillus Calmette-Guérin (BCG) immunotherapy, show promise in reducing recurrence rates. However, higher local recurrence rates and the need for frequent monitoring remain significant challenges. Conclusion: The evolution of endoscopic therapies has shifted the management of UTUC toward personalized, minimally invasive approaches that prioritize kidney preservation and quality of life. Despite challenges, including technical limitations and higher recurrence rates, advances in laser technologies, imaging systems, and intraluminal drug delivery provide a promising future for endoscopic treatment. Further research should aim to refine patient selection, improve risk stratification, and explore long-term oncological outcomes to solidify the role of endoscopic management as a standard alternative to RNU in appropriate cases.