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Urology: Upper-tract urothelial adjuvant chemotherapy

Free question published 14 September 2026

UrologyUpper-tract urothelial adjuvant chemotherapy

A 67-year-old man undergoes radical nephroureterectomy for upper-tract urothelial carcinoma. Final histology is pT3 N0, high grade, margins clear. His postoperative estimated glomerular filtration rate is 58 mL/min and his performance status is 0. He is reviewed in clinic 5 weeks after surgery. What is the most appropriate adjuvant management?

  1. AAdjuvant radiotherapy directed to the renal bed surgical resection site
  2. BAdjuvant intravesical BCG
  3. CAdjuvant gemcitabine-platinum combination chemotherapy
  4. DAdjuvant single-agent pembrolizumab
  5. ESurveillance with no adjuvant therapy

Why C is correct

The POUT trial showed that adjuvant gemcitabine-platinum chemotherapy started within 90 days of nephroureterectomy significantly improved disease-free survival in locally advanced (pT2 to pT4 or node-positive) upper-tract urothelial carcinoma (HR 0.45). With an eGFR of 58 mL/min he is cisplatin-eligible, and the authors concluded adjuvant platinum-based chemotherapy should be considered a new standard of care.

And why the others are not

  • AIncorrect: adjuvant renal-bed radiotherapy is not the POUT-supported standard for this setting.
  • BIncorrect: intravesical BCG treats non-muscle-invasive bladder disease, not the adjuvant management of resected upper-tract urothelial carcinoma.
  • DIncorrect: POUT established platinum-based chemotherapy, not single-agent adjuvant immunotherapy, as standard of care here.
  • EIncorrect: surveillance alone yielded inferior disease-free survival (3-year 46% vs 71%) in POUT.

Source POUT — Adjuvant chemotherapy in upper-tract urothelial carcinoma — Birtle A, Johnson M, Chester J, et al. Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): a phase 3, open-label, randomised controlled trial. Lancet 2020;395(10232):1268-1277.

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