Accuracy of photodynamic diagnosis in the detection and follow-up of patients with upper urinary tract lesions: Initial 3-year experience

Diagnostic performance of photodynamic diagnosis with oral 5-aminolevulinic acid for upper tract- and bladder urothelial carcinoma: a single-centre, retrospective analysis

PURPOSE

To compare the diagnostic performance of photodynamic diagnosis (PDD) enhanced with oral 5-aminolaevulinic acid between the suspected upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BUC) cases.

METHODS

This retrospective study included 18 patients with suspected UTUC who underwent ureteroscopy (URS) with oral 5-ALA in the PDD-URS cohort between June 2018 and January 2019; and 110 patients with suspected BUC who underwent transurethral resection of bladder tumour (TURBT) in the PDD-TURBT cohort between January 2019 and March 2023. Sixty-three and 708 biopsy samples were collected during diagnostic URS and TURBT, respectively. The diagnostic accuracy of white light (WL) and PDD in the two cohorts was evaluated, and false PDD-positive samples were pathologically re-evaluated.

RESULTS

The area under the receiver operating characteristic curve (AUC) of PDD was significantly superior to that of WL in both cohorts. The per biopsy sensitivity, specificity, and positive and negative predictive values of PDD in patients in the PDD-URS and PDD-TURBT cohorts were 91.2 vs. 71.4, 75.9 vs. 75.3, 81.6 vs. 66.3, and 88.0 vs. 79.4%, respectively. The PDD-URS cohort exhibited a higher AUC than did the PDD-TURBT cohort (0.84 vs. 0.73). Seven of four false PDD-positive samples (57.1%) in the PDD-URS cohort showed potential precancerous findings compared with eight of 101 (7.9%) in the PDD-TURBT cohort.

CONCLUSION

The diagnostic performance of PDD in the PDD-URS cohort was at least equivalent to that in the PDD-TURBT cohort.

Diagnosing upper tract urothelial carcinoma: A review of the role of diagnostic ureteroscopy and novel developments over last two decades

Objective

The role of ureteroscopy in the diagnosis of upper tract urothelial carcinoma is yet to be fully determined. We aimed to provide an up to date evaluation of its role and the emerging technologies in the field.

Methods

A literature search of the last two decades (from 24th May, 2001 to 24th May, 2021) was carried out identifying 147 papers for potential inclusion within this narrative review.

Results

Diagnostic ureteroscopy is undeniably useful in its ability to visualise and biopsy indeterminate lesions, and to risk stratify malignant lesions that may be suitable for kidney sparing surgery. However, an increased risk of intravesical recurrence following nephroureterectomy when a prior diagnostic ureteroscopy has been performed, inadequate sampling at biopsy, complications from the procedure, and difficult ureteric access are all potential drawbacks. Furthermore, whilst generally an accurate diagnostic procedure, it risks missing carcinoma in-situ lesions. Despite this, evidence shows that routine use of ureteroscopy changes the management of patients in a large proportion of cases, preventing unnecessary surgery or facilitating kidney sparing surgery. The overall rate of complications is low, and improved biopsy techniques and the use of tissue biomarkers for improved staging and grading are encouraging. The risks of delays to definitive management and post-ureteroscopy intravesical recurrence do not seem to affect survival, and trials are in progress to determine whether intravesical therapy can mitigate the latter. Further promising techniques are being investigated to improve shortcomings, particularly in relation to improved diagnosis of carcinoma in situ and preoperative staging.

Conclusion

Ureteroscopy has a role in the diagnosis of upper tract malignancy, though whether it should be used routinely is yet to be determined.

Photodynamic diagnostic ureteroscopy using the VISERA ELITE video system for diagnosis of upper-urinary tract urothelial carcinoma: a prospective cohort pilot study

Background

The advantages of photodynamic diagnostic technology using 5-aminolevulinic acid (ALA-PDD) have been established. The aim of this prospective cohort study was to evaluate the usefulness of ALA-PDD to diagnose upper tract urothelial carcinoma (UT-UC) using the Olympus VISERA ELITE video system.

Methods

We carried out a prospective, interventional, non-randomized, non-contrast and open label cohort pilot study that involved patients who underwent ureterorenoscopy (URS) to detect UT-UC. 5-aminolevulinic acid hydrochloride was orally administered before URS. The observational results and pathological diagnosis with ALA-PDD and traditional white light methods were compared, and the proportion of positive subjects and specimens were calculated.

Results

A total of 20 patients were enrolled and one patient who had multiple bladder tumors did not undergo URS. Fifteen of 19 patients were pathologically diagnosed with UT-UC and of these 11 (73.3%) were ALA-PDD positive. Fourteen of 19 patients were ALA-PDD positive and of these 11 were pathologically diagnosed with UC. For the 92 biopsy specimens that were malignant or benign, the sensitivity for both traditional white light observation and ALA-PDD was the same at 62.5%, whereas the specificities were 73.1% and 67.3%, respectively. Of the 38 specimens that were randomly biopsied without any abnormality under examination by both white light and ALA-PDD, 11 specimens (28.9%) from 5 patients were diagnosed with high grade UC. In contrast, four specimens from 4 patients, which were negative in traditional white light observation but positive in ALA-PDD, were diagnosed with carcinoma in situ (CIS).

Conclusions

Our results suggest that ALA-PDD using VISERA ELITE is not sufficiently applicable for UT-UC. Nevertheless, it might be better particularly for CIS than white light and superior results would be obtained using VISERA ELITE II video system.

Trial registration: The present clinical study was approved by the Okayama University Institutional Review Board prior to study initiation (Application no.: RIN 1803–002) and was registered with the UMIN Clinical Trials Registry (UMIN-CTR), Japan (Accession no.: UMIN000031205).

Diagnostic accuracy of photodynamic diagnosis for upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the effectiveness of photodynamic diagnosis (PDD) for upper urinary tract urothelial carcinoma (UTUC) by performing a meta-analysis.

METHOD

Relevant articles were retrieved from the Cochrane Library, PubMed, and Embase databases. Studies evaluating the accuracy of PDD for the diagnosis of upper UTUC were included. The pooled sensitivity, specificity, and area under the curve (AUC) were calculated by STATA 16.0 at the per-lesion level.

RESULTS

Six studies with 289 lesions were included in this systematic review and meta-analysis. The pooled results showed that PDD can differentiate upper UTUC from benign lesions with a sensitivity of 0.96 (95 % confidence interval: 0.85-0.99) and a specificity of 0.86 (95 % confidence interval: [0.64-0.95]; AUC, 0.97). Compared with white-light ureterorenoscopy, PDD can significantly improve the additional detection rate of UTUC (RR 0.16, 95 % CI 0.07-0.34 P = 0.000).

CONCLUSIONS

PDD is a valid technique that improves the diagnostic accuracy of UTUC compared with standard white-light ureterorenoscopy at the per-lesion level. PDD is a promising endoscopic technique for upper UTUC.

Novel real-time optical imaging modalities for the detection of neoplastic lesions in urology: a systematic review

BACKGROUND

Current optical diagnostic techniques for malignancies are limited in their diagnostic accuracy and lack the ability to further characterise disease, leading to the rapidly increasing development of novel imaging methods within urology. This systematic review critically appraises the literature for novel imagining modalities, in the detection and staging of urological cancer and assesses their effectiveness via their utility and accuracy.

METHODS

A systematic literature search utilising MEDLINE, EMBASE and Cochrane Library Database was conducted from 1970 to September 2018 by two independent reviewers. Studies were included if they assessed real-time imaging modalities not already approved in guidelines, in vivo and in humans. Outcome measures included diagnostic accuracy and utility parameters, including feasibility and cost.

RESULTS

Of 5475 articles identified from screening, a final 46 were included. Imaging modalities for bladder cancer included optical coherence tomography (OCT), confocal laser endomicroscopy, autofluorescence and spectroscopic techniques. OCT was the most widely investigated, with 12 studies demonstrating improvements in overall diagnostic accuracy (sensitivity 74.5-100% and specificity 60-98.5%). Upper urinary tract malignancy diagnosis was assessed using photodynamic diagnosis (PDD), narrow band imaging, optical coherence tomography and confocal laser endomicroscopy. Only PDD demonstrated consistent improvements in overall diagnostic accuracy in five trials (sensitivity 94-96% and specificity 96.6-100%). Limited evidence for optical coherence tomography in percutaneous renal biopsy was identified, with anecdotal evidence for any modality in penile cancer.

CONCLUSIONS

Evidence supporting the efficacy for identified novel imaging modalities remains limited at present. However, OCT for bladder cancer and PDD in upper tract malignancy demonstrate the best potential for improvement in overall diagnostic accuracy. OCT may additionally aid intraoperative decision making via real-time staging of disease. Both modalities require ongoing investigation through larger, well-conducted clinical trials to assess their diagnostic accuracy, use as an intraoperative staging aid and how to best utilise them within clinical practice.

Endoscopic Approaches to Upper Tract Urothelial Carcinoma

A select group of patients with upper tract urothelial carcinoma (UTUC) may meet indications for endoscopic management. Strategies for disease management are provided, based on a comprehensive review of the data using PubMed and Medline databases and marrying this with our experience with endoscopic management of UTUC. Endoscopic management of UTUC via retrograde or antegrade approaches is a viable treatment option for appropriately selected patients with low-risk UTUC, including those with low-grade, low-volume, and solitary tumors. However, recurrence risk limits these procedures to compliant patients under a vigilant surveillance program. Efficacious adjuvant therapies are needed to reduce local recurrences.

Ureteroscopy in the diagnosis of upper tract transitional cell cancer: a 10-year experience providing outcome data for informed consent

PURPOSE

The aim of the study was to assess the effectiveness of ureteroscopy and biopsy in the diagnosis and management of upper tract urothelial carcinoma.

METHODS

We retrospectively collated data from pathology, radiology and operating theatre data sets from two large UK hospitals. During the 10-year period examined, 160 patients underwent ureteroscopy prior to nephro-ureterectomy (NU)/distal ureterectomy (DU).

RESULTS

Of the 160 patients identified, 140 were ureteroscopically evaluated and biopsied, 104 (74.3%) had positive biopsies, 5 (3.6%) had negative biopsies and 31 (22.1%) had nondiagnostic biopsies.One hundred and forty patients of 160 (88.8%) resulted in positive findings as a result of their ureteroscopy [positive biopsy/positive operative cytology/visible upper tract urothelial carcinoma (UTUC) at ureteroscopy)].A total of 108 patients had cytological samples sent for histological analysis where grade was able to be assessed at DU/NU. Of these samples, 35 had positive cytology, 58 had an abnormal result that was not diagnostic and 15 had negative cytology.Patients with positive biopsies had upstaging (58.4%) and/or upgrading (30.5%) of their initial ureteroscopic histology at NU/DU.The overall success rate of ureteroscopy for cancer diagnosis was 88.8%.

CONCLUSIONS

Upper tract endoscopy and biopsy yielded positive biopsy results in 74.3% of cases and confirmed a cancer diagnosis in 88.8%. Five patients had negative histology at biopsy, all of whom eventually underwent a NU/DU confirming cancer.

Photodynamic diagnosis in upper urinary tract urothelial carcinoma: A systematic review

Objective

To assess the diagnostic accuracy and safety of photodynamic diagnosis (PDD) in upper urinary tract urothelial carcinoma (UUTUC).

Materials and methods

A systematic literature search was conducted. Included studies were assessed for the risks of bias and quality using appropriate tools. Dedicated data extraction forms were used. Diagnostic accuracy in terms of sensitivity and specificity were quoted whenever provided by individual studies. A combined toxicity profile of 5-aminolevulinic acid (5ALA) was given after reviewing individual studies.

Results

In all, 17 studies were identified. After screening seven studies were included involving a total of 194 patients. None of the studies were randomised. All the available studies were of low-to-moderate quality. The largest available study, with 106 patients, reported a sensitivity of 95.8% and 53.5% for PDD and white-light (WL) ureterorenoscopy (URS) respectively, with a statistically significant difference. The specificity was 96.6% for PDD and 95.2% for WL-URS with no statistical significance. PDD showed better ability in detecting carcinoma in situ and dysplasia. One study compared PDD to computed tomography urogram (CTU) and found PDD to have better sensitivity and statistically significantly better specificity. 5ALA-associated toxicity was minor in nature and hypotension was the most common adverse event.

Conclusion

PDD in UUTUC appears to be more accurate than WL-URS and CTU, with no significant toxicity. Larger scale randomised trials are needed.

Oral 5-aminolevulinic acid induced Photodynamic Diagnostic Ureterorenoscopy--does the blood pressure require monitoring?

BACKGROUND

Photodynamic Diagnosis has been proven to improve detection of superficial bladder cancer and improve visualisation of resection margins. The use of 5-aminolevulinic acid as the photosensitising agent has been associated with side effects, specifically hypotension. We aimed to evaluate the effect of oral 5-ALA on the blood pressure in a group of patient who underwent Photodynamic Diagnostic Ureterorenoscopy.

METHODS

We carried out an observational study on all patients who underwent PDD-Ureterorenoscopy with oral 5-ALA between July 2009 and September 2011. Pre-administration, hourly post-administration and hourly post-operative blood pressures were noted. Mean arterial blood pressure and the threshold for cerebral ischaemia were calculated as well.

RESULTS

The study includes thirty-eight procedures which involved twenty-four patients with a mean age of 74 (SD±16.95). Hypotension was defined as <80% of the systolic or diastolic baseline blood pressure. Twenty patients were hypotensive pre-operatively after the ingestion of 5-ALA while 21 patients were hypotensive post-operatively. Three patients crossed their MAP threshold pre-operatively and were symptomatic. Fast infusion of intravenous fluids improved their symptoms.

CONCLUSION

Hypotension is a common occurrence after the ingestion of 5-ALA. Patients undergoing PDD Ureterorenoscopy should have their blood pressure monitored closely after the ingestion of 5-ALA.