Editor's Note: From August 8 to 11, 2024, the Annual Meeting of the Urological Surgeons Branch of the Chinese Medical Association (CUDA) was held in Xi'an. The conference was hosted by the Chinese Medical Association and the CUDA Urological Surgeons Branch, with the Air Force Medical University Xijing Hospital as the organizer and the Shaanxi Provincial Medical Association Urological Surgeons Branch as a co-organizer. Under the theme of "Healthy China, Urology First," the conference gathered many of the latest achievements in urology. At the event, Urology Frontier invited Dr. Xuesong Li, Dr. Qi Tang, and Dr. Xiaoying Li from Peking University First Hospital for an in-depth discussion on the current state of non-invasive detection, radiotherapy, and translational medicine for upper tract urothelial carcinoma (UTUC). They also shared their experiences in building subspecialties for UTUC and outlined the direction in which CUDA-UTUC is leading the field.

01 Urology Frontier: As the head of a leading national urological oncology research institution, could you share the background of establishing a UTUC subspecialty and its positive impact on clinical practice?

Dr. Xuesong Li: UTUC includes renal pelvis cancer and ureteral cancer, both of which are classified as urothelial carcinomas. Because UTUC occurs in the upper urinary tract, such as the renal pelvis and ureter, it is referred to as upper tract urothelial carcinoma. In China, UTUC is a cancer with distinctly local characteristics, often associated with the use of traditional Chinese medicines, lifestyle habits, and exposure to toxic substances, closely related to daily life. The incidence of UTUC in China significantly differs from that in other countries. While UTUC is considered a rare disease in Western textbooks, it is relatively common in China, with both the absolute number of cases and the overall proportion being markedly higher than abroad. Given the unique pathogenesis and epidemiological characteristics of UTUC in China, during our participation in the American Urological Association Annual Meeting in 2008, international experts pointed out that due to potential differences between Asian and Western UTUC, Western guidelines might not be directly applicable in China. Since then, our urological oncology subspecialty at Peking University First Hospital has been dedicated to the diagnosis and treatment of UTUC and continues to this day. Today, our multidisciplinary team, including urology, radiotherapy, oncology, and imaging departments, has made significant contributions in this field.

02 Urology Frontier: With the advent of the precision era, what indicators are available for non-invasive detection of urothelial carcinoma?

Dr. Qi Tang: In the non-invasive detection of urothelial carcinoma, we utilize traditional methods such as urine cytology, bladder tumor antigen (BTA), urine nuclear matrix protein 22 (NMP22), and urine fluorescence in situ hybridization (FISH). However, these methods have certain limitations. For example, classic urine cytology, while highly specific, only has a sensitivity of 30% to 40%. Urine FISH improves both specificity and sensitivity to about 70% to 80%, but its clinical use is still somewhat limited. For many years, we have focused considerable effort on urine-related non-invasive detection, including DNA methylation detection, urine exosome detection, and multi-omics detection methods based on next-generation sequencing (NGS). These newer methods offer more accurate early diagnosis of urothelial carcinoma compared to traditional techniques.

03 Urology Frontier: Currently, 35% to 50% of patients with locally advanced UTUC are at high risk of disease progression post-surgery. What value does adjuvant radiotherapy offer these patients, and how should radiotherapy strategies be selected?

Dr. Xiaoying Li: UTUC has a poorer prognosis and a higher postoperative recurrence rate compared to lower urinary tract tumors such as bladder cancer. This may be due to a higher proportion of advanced tumors at diagnosis and a lower rate of standardized lymph node dissection during UTUC surgery. Additionally, research on adjuvant therapy for UTUC is less extensive than for bladder cancer. International guidelines only provide a single recommendation for adjuvant chemotherapy, but since less than 30% of patients can tolerate full-dose chemotherapy postoperatively due to the loss of a kidney, adjuvant chemotherapy offers no benefit for those with impaired kidney function. As a result, many patients with advanced disease do not receive effective adjuvant treatment post-surgery, increasing the risk of recurrence and metastasis. Although immunotherapy has shown benefits in clinical studies for urothelial carcinoma, it has not demonstrated the same benefits for UTUC patients. Therefore, the optimal adjuvant treatment model for UTUC post-surgery remains to be explored.

Adjuvant radiotherapy has been shown to reduce local recurrence risk and improve survival when combined with adjuvant drug therapy in many other cancers, such as breast and bladder cancers. Based on the Departure database (Epidemiology, Examination, Therapy, and Result: Upper-tract Urothelial Carcinoma) established by the Urology Department at Peking University First Hospital, our retrospective studies have identified patient populations that could benefit from adjuvant radiotherapy post-surgery, and these findings have been cited in the NCCN guidelines, which confirm that postoperative radiotherapy can reduce the local recurrence rate of UTUC. We are currently conducting prospective clinical trials to explore the combination of adjuvant radiotherapy with drug therapies, hoping to achieve synergistic effects that provide new treatment options for UTUC patients.

For UTUC patients with different primary tumor locations, we have also personalized postoperative radiotherapy plans at Peking University First Hospital to enhance treatment effectiveness while minimizing side effects.

04 Urology Frontier: What other explorations are your team undertaking in the diagnosis and treatment of urothelial carcinoma? How do you plan to further translate basic research into clinical practice to benefit patients?

Dr. Qi Tang: As mentioned earlier, urine-related non-invasive detection is a new technology, and how to apply it clinically is a critical question. We are working to integrate these new detection methods more closely with clinical practice. From the perspective of early disease diagnosis, cystoscopy is very convenient for bladder cancer, but UTUC cystoscopy is much more challenging. Some studies have shown that preoperative UTUC cystoscopy may increase the risk of bladder recurrence in patients. Therefore, novel non-invasive detection technologies are an excellent supplementary method for the early diagnosis of UTUC. Moreover, we can also use non-invasive detection techniques to evaluate treatment efficacy. Many centers are now trying nephron-sparing treatments for UTUC, but there is no consensus on how to assess efficacy post-treatment. If we can use non-invasive detection methods for monitoring post-treatment efficacy, these techniques will have significant clinical application potential.

05 Urology Frontier: The treatment of UTUC cannot be separated from the support of a multidisciplinary team (MDT). How should different areas of expertise be integrated to maximize patient survival time and quality of life?

Dr. Xiaoying Li: In cancer treatment, surgery, drug therapy, and radiotherapy are all indispensable. In the field of UTUC, our Department of Radiotherapy at Peking University First Hospital has conducted several related studies, primarily in three areas: First, for patients who have undergone radical surgery, we are actively exploring the characteristics of patient populations suitable for adjuvant therapy to minimize the risk of postoperative recurrence and achieve long-term disease-free survival. Second, for UTUC patients with solitary kidneys or chronic kidney disease, surgery may place them at risk of dialysis, and elderly patients may not tolerate surgery due to anesthesia risks. In the past, the prognosis for these patients was poor, and drug therapy alone was not very effective. In recent years, with the support of our urological oncology MDT, we have actively explored nephron-sparing treatment methods for UTUC based on radiotherapy, and preliminary results have proven the efficacy and safety of this approach. Third, for patients with metastatic UTUC, although novel targeted and immunotherapy drugs have made some progress compared to traditional chemotherapy, overall efficacy remains limited compared to other cancer types. Combining local radiotherapy with drug therapy to improve prognosis for metastatic UTUC patients is a key area of research for us going forward.

06 Urology Frontier: What future work will the CUDA-UTUC collaboration group undertake to further improve UTUC diagnosis and treatment in China?

Dr. Xuesong Li: Let’s first summarize the characteristics of UTUC: it is considered a rare disease internationally, but its distribution is uneven within China. Although our department treats 300 to 400 patients each year, the number of patients treated and the level of diagnosis and treatment vary greatly across different institutions. Currently, many clinical issues related to UTUC remain unresolved, and there are numerous pathways in the guidelines that need to be further explored, requiring high-level evidence-based medical evidence for support. On one hand, generating high-level evidence-based medical evidence requires high-level hospitals to conduct in-depth explorations, identify key issues, data, and trends, and solve problems through multicenter, prospective, randomized, controlled clinical trials to revise the guidelines. On the other hand, it is necessary to summarize and develop personalized diagnosis and treatment pathways. Many unresolved challenges remain in the diagnosis, treatment, prognosis, and follow-up of UTUC, requiring the collaboration of multiple centers and disciplines under the organization of the academic society to further increase data volume and enhance the depth, height, and breadth of evidence-based medical evidence. This will enable the diagnosis and treatment of UTUC to achieve a high level of consistency both in guideline development and personalized treatment.

With the joint initiation and organization of Peking University First Hospital, Sichuan University West China Hospital, Shanghai Jiao Tong University Affiliated Renji Hospital, Tianjin Medical University Second Hospital, and dozens of other institutions with strong organization and achievements, we have formed the CUDA-UTUC collaboration group and the China UTUC Alliance. We hope that under the organization of the CUDA academic society, the CUDA-UTUC collaboration group, and the China UTUC Alliance, we can gradually clarify and solve UTUC-related issues one by one, thus serving more doctors, colleagues, and patients.

Dr. Xuesong Li

  • Chief Physician and Professor
  • PhD Supervisor and Postdoctoral Supervisor, Peking University Health Science Center
  • Director, Department of Urology, Peking University First Hospital
  • Deputy Director, Urology Training Institute, Peking University
  • Curator, Beijing Urological Endoscopy Museum
  • Leader, Upper Urinary Tract Reconstruction Group, Peking University Urology Research Institute
  • Committee Member and Deputy Secretary-General, CUDA Urological Surgeons Branch of the Chinese Medical Association (CUDA)
  • Deputy Director, Urology and Andrology Branch, Chinese Medical and Health International Exchange Promotion Association
  • Member, Robotics Group, Chinese Urological Association (CUA), and Deputy Secretary-General
  • Deputy Leader, Reconstructive and Restorative Surgery Group, CUDA
  • Leader, Upper Urinary Tract Reconstruction Collaboration Group, CUDA
  • Deputy Leader, Digital and Artificial Intelligence Group, CUDA
  • Vice Chairperson, Postgraduate Medical Education (Surgery – Urology) Professional Committee, Chinese Medical Association
  • Standing Committee Member, Second Committee of the Artificial Intelligence and Medical Robotics Working Committee, China Medical Equipment Association
  • Committee Member, Surgery Group, Fifth Committee of the Evidence-Based Medicine Professional Committee, Chinese Medical Association
  • Committee Member, Minimally Invasive Surgery Group, Urology and Andrology Professional Committee, Chinese Anti-Cancer Association
  • Deputy Leader, Urinary Tract Reconstruction and Reconstruction Group, Beijing Urological Association
  • Chairperson, Urological Oncology Professional Committee, Beijing Cancer Prevention and Treatment Association
  • Committee Member, Clinical Research Committee, Asian Robotic Urological Society (ARUS)
  • Academic Chair, World Society of Robotic Surgery (SRS)
  • Published over 330 papers in Chinese and English journals, with more than 180 SCI papers as the first or corresponding author in top journals such as EU and JU. Holds 15 national utility model patents, co-authored or edited 23 urology professional books, translated six books, and edited seven books.
  • Specializes in the surgical treatment, clinical translation, and basic research of urinary tumors and ureteral diseases. Presided over three National Natural Science Foundation projects, one Ministry of Science and Technology key research project (project leader), two Beijing Natural Science Foundation projects, one Beijing Science and Technology Plan project, and one Capital Health Development Research Special Key Project, with a total research funding of over 27 million yuan. Received more than eight provincial and ministerial-level awards.

Dr. Qi Tang

  • Associate Chief Physician, Department of Urology, Peking University First Hospital
  • PhD in Clinical Medicine, Peking University
  • Master’s in Clinical Genetics and Genetic Counseling, University of Manchester, UK
  • Sixth Batch of “Team-Style” Medical Experts Supporting Tibet from the Ministry of Organization
  • Champion of the National Finals of the Third “CARS All-around Doctor” China Renal Cancer Comprehensive Treatment Challenge
  • Runner-up of the National Finals of the 2019 “Who Dares Wins” Prostate Cancer Diagnosis and Treatment Forum
  • Member of the Urology and Andrology Professional Committee, Chinese Anti-Cancer Association
  • Member of the Chinese Society of Clinical Oncology

Dr. Xiaoying Li

  • MD, Associate Chief Physician
  • Peking University First Hospital
  • Expertise: breast cancer, lung cancer, renal pelvis and ureteral cancer, and palliative care for advanced tumors
  • Academic Positions: Second Youth Committee Member, Oncology Branch of Beijing Medical Association; Committee Member, Urological Oncology Professional Committee, Beijing Cancer Prevention and Treatment Association; Youth Committee Member, Beijing Cancer Prevention and Treatment Association; Committee Member, Radiotherapy Professional Committee, Beijing Cancer Prevention and Treatment Association; Executive Member and Deputy Secretary-General, Youth Committee of the Tumor Radiotherapy Committee of the Wu Jieping Medical Foundation; Committee Member, Head and Neck Professional Committee of the China Health Promotion Foundation; Committee Member, Palliative Care Committee of the Beijing Anti-Cancer Association; Executive Member of the Second Youth Academic Professional Committee of the Beijing Breast Disease Prevention and Control Society; Committee Member and Secretary-General, Radiotherapy Professional Committee, Beijing Breast Disease Prevention and Control Society; Committee Member, Radiotherapy Group, Youth Expert Committee on Lung Cancer Medicine, Beijing Medical Award Foundation; Youth Deputy Editor-in-Chief, Radiotherapy Channel, Medical Reference News; Editor-in-Chief.
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Last updated on 2024.09.03