European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update

Intravesical Instillation of Chemotherapy Before Radical Surgery for Upper Urinary Tract Urothelial Carcinoma: The REBACARE Trial

BACKGROUND AND OBJECTIVE

Intravesical instillation of chemotherapy (IIC) after radical surgery for upper urinary tract urothelial carcinoma (UTUC) reduces the risk of intravesical recurrence (IVR). However, compliance is low because of possible extravesical leakage after bladder cuff excision. The aim of this study was to evaluate the efficacy of preoperative IIC in reducing the risk of IVR.

METHODS

In this prospective, single-arm, multi-institutional, phase 2 clinical trial, 190 chemonaïve patients with primary UTUC without prior or concurrent bladder cancer received a single intravesical instillation of mitomycin C for 1-2 hr within 3 h before surgery. The primary endpoint was the 2-yr histologically confirmed IVR rate, with a target reduction of >40% (from 33.2% according to literature data to <20%). A historical cohort of 247 patients with UTUC who did not receive perioperative IIC served as the reference. Secondary endpoints included compliance, toxicity, and IVR-free survival, which was analyzed via multivariable Cox regression and stratified by previous diagnostic ureteroscopy (d-URS).

KEY FINDINGS AND LIMITATIONS

The 2-yr IVR rate was 24% (95% confidence interval [CI] 18-31%) on intention-to-treat analysis and 23% (95% CI 13-32%) on per-protocol analysis. Multivariable analysis revealed that d-URS was associated with higher IVR risk. In the REBACARE cohort, patients without d-URS had threefold lower IVR risk (hazard ratio 0.33, 95% CI 0.12-0.87) in comparison to the reference cohort. Compliance with preoperative instillation was 96% and no grade >2 toxicity occurred.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Preoperative IIC with mitomycin C was feasible and well tolerated and significantly reduced IVR risk for patients without d-URS. These findings suggest that preoperative IIC is a viable strategy for this subset of UTUC patients and that d-URS should be performed judiciously.

Drug classes associated with the development of fulminant type 1 diabetes: a retrospective analysis using the FDA adverse event reporting system database

BACKGROUND

Fulminant type 1 diabetes mellitus (FT1DM) is a severe subtype of type 1 diabetes characterized by rapid onset, metabolic disturbances, and irreversible insulin secretion failure. Recent studies have suggested associations between FT1DM and certain medications, warranting further investigation.

OBJECTIVES

This study aims to identify drugs associated with an increased risk of FT1DM using the FDA Adverse Event Reporting System (FAERS) database, evaluate reporting patterns, and provide actionable insights to reduce FT1DM occurrence and improve medication safety.

METHODS

A retrospective analysis of FAERS data from 2013 to 2023 was conducted. Drug names were standardized using text mining tools, and safety signals were evaluated using reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS).

RESULTS

A total of 706 FT1DM cases were identified, predominantly in older individuals and males. Nineteen drugs were implicated, including immune checkpoint inhibitors (nivolumab, ipilimumab, pembrolizumab, avelumab, durvalumab, atezolizumab), lenvatinib, eribulin, psychiatric drugs (atomoxetine, carbamazepine, lamotrigine), anti-infectives (sulfamethoxazole, trimethoprim, amoxicillin), and metabolic modulators (dapagliflozin, sitagliptin, hydrochlorothiazide, allopurinol).

CONCLUSION

This study highlights drugs potentially triggering FT1DM and emphasizes the need for pharmacovigilance and glucose monitoring in patients treated with these medications.

Hematuria in the ER patient: optimizing detection of upper tract urothelial cancer - A pictorial essay

Upper tract urothelial carcinoma (UTUC) is a rare and challenging subset of the more frequently encountered urothelial carcinomas (UCs), comprising roughly 5-7% of all UCs and less than 10% of all renal tumors. Hematuria is a common presenting symptom in the emergency setting, often prompting imaging to rule out serious etiologies, with UTUC especially posing as a diagnostic challenge. These UTUC lesions of the kidney and ureter are often small, mimicking other pathologies, and are more aggressive than typical UC of the bladder, emphasizing the importance of timely and accurate diagnosis. Multidetector computed tomography urography (CTU) is the standard imaging modality for diagnosis, tumor staging, and surgical planning. Various postprocessing techniques like multiplanar reconstructions, maximal intensity projection (MIP) images, and 3D volumetric rendering technique (VRT) are crucial for accurate detection. In addition, 3D cinematic rendering (CR) is a novel technique that employs advanced illumination models, producing images with realistic shadows and increased surface detail, outperforming traditional VRT. We will review the distinctive imaging features between UTUC and infiltrating mimicking lesions on CTU in patients who presented with hematuria, in conjunction with advanced postprocessing techniques, ultimately improving diagnostic confidence and preoperative planning in the emergency context.

Application of Raman Spectroscopy in the Non-invasive Diagnosis of Urological Diseases via Urine

OBJECTIVES

The objective of this review is to provide a comprehensive overview of the utilization of Raman spectroscopy in urinary system diseases, highlighting its potential in non-invasive diagnostic methodologies for early diagnosis and prognostic assessment of urinary ailments.

METHODS

We searched PubMed, Web of Science, and Google Scholar using 'raman,' 'bladder,' 'kidney,' 'prostate,' 'cancer,' 'infection,' 'stone or urinary calculi,' and 'urine or urinary,' along with 'AND' and 'OR' to refine our search. We excluded irrelevant articles and screened potential ones based on titles and abstracts before assessing the full texts for relevance and quality.

FINDINGS

The findings indicate that RS can furnish data on biomolecules in urine, which is significant for non-invasive diagnostic approaches. It has shown potential within non-invasive diagnostic methodologies and is expected to play a pivotal role in the early diagnosis and prognostic assessment of urinary system diseases, such as malignancies, urinary tract infections, kidney diseases, urolithiasis, and other urinary conditions.

CONCLUSIONS

Raman spectroscopy has demonstrated significant potential in providing precise and rapid diagnostic approaches for clinical use in the context of urinary system diseases. Its ability to analyze biomolecules non-invasively positions it as an increasingly important tool in the early diagnosis and prognostic assessment of these conditions.

Case report: A rare case of delayed drug-induced hyponatremia in recurrent upper tract urothelial carcinoma following GC and Tislelizumab treatment

Drug-induced hyponatremia is an adverse reaction with accelerated electrolyte disturbance. This study reported a rare case of delayed hyponatremia in a 68year-old female with recurrent upper tract urothelial carcinoma after Gemcitabine plus Cisplatin (GC) and Tislelizumab treatment. She had left ureter surgery, recurrence a year later with mildly abnormal kidney function (glomerular filtration rate (GFR) was 54.9 ml/min). After the first cycle of GC plus Tislelizumab, severe hyponatremia leading to life-threatening conditions occurred eight days later. Hypothesizing Cisplatin as the cause, its usage was modified in the second cycle (40mg/day for three days). No severe hyponatremia followed. CT showed partial remission. From the third cycle, due to grade IV bone marrow suppression, she had Tislelizumab alone. Now, she is on 21-day Tislelizumab maintenance with a stable tumor status. Low-dose continuous Cisplatin may suit patients with borderline or mildly abnormal renal function (GFR: 40-60mL/min) better than single full-dose use. Tislelizumab alone for maintenance may be an option for those intolerant of chemotherapy. But Na+ decrease may be related to Tirelizumab or Gemcitabine, needing more clinical observation and experiments.

Nuclear Medicine and Molecular Imaging in Urothelial Cancer: Current Status and Future Directions

Background: The role of molecular imaging in urothelial cancer is less defined than other cancers, and its utility remains controversial due to limitations such as high urinary tracer excretion, complicating primary tumour assessment in the bladder and upper urinary tract. This review explores the current landscape of PET imaging in the clinical management of urothelial cancer, with a special emphasis on potential future advancements including emerging novel non-18F FDG PET agents, PET radiopharmaceuticals, and PET-MRI applications. Methods: We conducted a comprehensive literature search in the PubMed database, using keywords such as "PET", "PET-CT", "PET-MRI", "FDG PET", "Urothelial Cancer", and "Theranostics". Studies were screened for relevance, focusing on imaging modalities and advances in PET tracers for urothelial carcinoma. Non-English language, off-topic papers, and case reports were excluded, resulting in 80 articles being selected for discussion. Results: 18F FDG PET-CT has demonstrated superior sensitivity over conventional imaging, such as contrast-enhanced CT and MRI, for detecting lymph node metastasis and distant disease. Despite these advantages, FDG PET-CT is limited for T-staging of primary urothelial tumours due to high urinary excretion of the tracer. Emerging evidence supports the role of PETC-CT in assessing response to neoadjuvant chemotherapy and in identifying recurrence, with a high diagnostic accuracy reported in several studies. Novel PET tracers, such as 68Ga-labelled FAPI, have shown promising results in targeting cancer-associated fibroblasts, providing higher tumour-to-background ratios and detecting lesions missed by traditional imaging. Antibody-based PET tracers, like those targeting Nectin-4, CAIX, and uPAR, are under investigation for their diagnostic and theranostic potential, and initial studies indicate that these agents may offer advantages over conventional imaging and FDG PET. Conclusions: Molecular imaging is a rapidly evolving field in urothelial cancer, offering improved diagnostic and prognostic capabilities. While 18F FDG PET-CT has shown utility in staging, further prospective research is needed to establish and refine standardised protocols and validate new tracers. Advances in theranostics and precision imaging may revolutionise urothelial cancer management, enhancing the ability to tailor treatments and improve patient outcomes.

The correlation between discrepancies in clinical and pathological T stages and overall survival in upper urinary tract urothelial carcinoma: Analysis of the hospital-based cancer registry data in Japan

OBJECTIVE

Our study assessed the correlation between discrepancies in clinical and pathological T stages and overall survival (OS) in patients with upper urinary tract urothelial carcinoma (UTUC), including renal pelvis (UCP) and ureter (UCU) carcinoma, treated with radical surgery.

METHODS

We utilized data from the Japanese Hospital-Based Cancer Registry (HBCR) to identify UTUC cases (n = 2376), consisting of UCP cases (n = 1196) and UCU cases (n = 1180), diagnosed with cTa-3N0M0 between 2012 and 2013. All cases were histologically confirmed and treated solely with radical surgery, excluding any chemotherapy or radiotherapy. We investigated the correlation between stage classification discrepancies and OS.

RESULTS

Among UCP and UCU patients, cT2N0M0 had the highest discrepancy rates between clinical and pathological stages (68% and 51%), while cT3N0M0 had the lowest (21% and 20%). Among UCP and UCU patients with cTa/is/1N0M0, those with up-staging showed significantly worse OS compared to same-staging (HR 1.7 and 2.5, p = 0.001 and <0.001, respectively). In UCU patients with cT2N0M0, the 5-year OS rates were 41.9% for up-staging, 63.7% for same-staging, and 76.4% for down-staging, with significantly worse survival in the up-staged group. Among UCP and UCU patients with cT3N0M0, the 5-year OS rates were 29.3% and 7.7% for those with up-staging, 53.7% and 30.6% for those with same staging, and 79.6% and 65.4% for those with down-staging.

CONCLUSION

Using a large real-world cohort, we found stage discrepancies to be a significant independent prognostic factor in non-metastatic UTUC patients. Treatment should be carefully selected, considering T-staging discrepancies and prognosis.

Advances in research on the carcinogenic mechanisms and therapeutic potential of YAP1 in bladder cancer (Review)

Bladder cancer is the most common malignant tumor of the urinary system with high morbidity and no clear pathogenesis. The Hippo signaling pathway is an evolutionarily conserved pathway that regulates organ size and maintains tissue homeostasis. Yes‑associated protein 1 (YAP1) is a key effector of this pathway and regulates downstream target genes by binding to transcriptional co‑activators with PDZ binding sequences (TAZ). Several studies have demonstrated that YAP1 is overexpressed in bladder cancer and is involved in adverse outcomes such as bladder cancer occurrence, progression, resistance to cisplatin and the recurrence of tumours. The present review summarized the involvement of YAP1 in bladder cancer disease onset and progression, and the mechanism of YAP1 involvement in bladder cancer treatment. In addition, this study further explored the potential of YAP1 in the diagnosis and treatment of bladder cancer. This study aimed to explore the potential mechanism of YAP1 in the treatment of bladder cancer.

Effect of indwelling ureteral stents on sexual function: a real-world observational study

BACKGROUND

Ureteral DJ stents are commonly used devices in urology. However, stent placement may cause LUTS and affect the quality of life. We evaluated the direct relationship between ureteral stents and sexual function.

METHODS

From October 2022 to December 2023, 82 male and 90 female sexually active patients who underwent ureteroscopy at Beijing Tiantan Hospital, Capital Medical University, were enrolled. The basic information, surgical data, and two questionnaire data including the International Index of Erectile Function-5 and the Female Sexual Function Index of patients before the operation (baseline, T0), on the day of the ureteral DJ tube extraction (T1), and 4 weeks after ureteral DJ tube extraction (T2) were collected to analyze the changes in the patients' sexual function.

RESULTS

The average age of male patients was 36 years and of female patients 39 years. Before the ureteral DJ stent placement, the mean ± SD IIEF-5 score was 22.86 ± 0.91, and the average FSFI score was 31.66 ± 1.44. On the day of the ureteral DJ stent removal, the IIEF-5 score was 16.37 ± 2.62 (p < 0.01) and the FSFI score was 15.83 ± 4.05 (p < 0.01). Four weeks after ureteral DJ stent removal, the average IIEF-5 score was 22.77 ± 1.06 (p = 0.61) and the average FSFI score was 30.99 ± 1.79 (p = 0.78).

CONCLUSIONS

Indwelling ureteral stents after ureteroscopy can temporarily affect the sexual function of both male and female patients, typically recovering within 4 weeks after stent removal.

Multi-DECT Image-based Intratumoral and Peritumoral Radiomics for Preoperative Prediction of Muscle Invasion in Bladder Cancer

OBJECTIVES

To assess the predictive value of intratumoral and peritumoral radiomics based on Dual-energy CT urography (DECTU) multi-images for preoperatively predicting the muscle invasion status of bladder cancer (BCa).

MATERIAL AND METHODS

This retrospective analysis involved 202 BCa patients who underwent DECTU. DECTU-derived quantitative parameters were identified as risk factors through stepwise regression analysis to construct a DECT model. The radiomic features from the intratumoral and 3 mm outward peritumoral regions were extracted from the 120 kVp-like, 40 keV, 100 keV, and iodine-based material-decomposition (IMD) images in the venous-phase and were screened using Mann-Whitney U test, Spearman correlation analysis, and LASSO. Radiomics models were developed using the Multilayer Perceptron for the intratumoral, peritumoral and intra- and peritumoral (IntraPeri) regions. Subsequently, a nomogram was created by integrating the multi-image IntraPeri radiomics and DECT model. Model performance was evaluated using area-under-the-curve (AUC), accuracy, sensitivity, and specificity.

RESULTS

Normalized iodine concentration (NIC) was identified as an independent predictor for the DECT model. The IntraPeri model demonstrated superior performance compared to the intratumoral and peritumoral models both in 40 keV (0.830 vs. 0.766 vs. 0.763) and IMD images (0.881 vs. 0.840 vs. 0.821) in the test cohort. In the test cohort, the nomogram exhibited the best predictability (AUC=0.886, accuracy=0.836, sensitivity=0.737, and specificity=0.881), outperformed the DECT model (AUC=0.763, accuracy=0.754, sensitivity=0.632, and specificity=0.810) in predicting muscle invasion status of BCa with a statistically significant difference (p < 0.05).

CONCLUSION

The nomogram, incorporating IntraPeri radiomics and NIC, serves as a valuable and non-invasive tool for preoperatively assessing the muscle invasion status of BCa.

Co‑occurrence of clear cell renal cell carcinoma and bladder urothelial carcinoma: A case report and literature review

The co-occurrence of clear cell renal cell carcinoma (ccRCC) and bladder urothelial carcinoma (bUC) is rare, and owing to the lack of a unified treatment plan, the prognosis is poor. The present report describes the case of a 65-year-old male patient with a history of smoking and no history of malignant tumors who presented with hematuria at the Huanghe Sanmenxia Hospital Affiliated to Henan University of Science and Technology (Sanmenxia, China) in July 2021. Urinary system computed tomography urography revealed a right renal tumor, and cystoscopy revealed intravesical lesions. The patient underwent transurethral resection of a bladder tumor + laparoscopic partial nephrectomy + laparoscopic radical cystectomy and bilateral ureterostomy. Pathological examination revealed right-sided ccRCC (pT1aN0M0) and high-grade invasive bUC (pT2N0M0). After surgery, the patient underwent bilateral ureteral single J tube replacement in the outpatient clinic every 3 months. In September 2022, the patient presented with a mass on the right side of the neck. Further examination revealed a space-occupying lesion in the lower part of the left kidney and space-occupying lesions in the neck, axilla, mediastinal lymph nodes and liver. A neck lymph node puncture biopsy suggested UC, and the patient was diagnosed with metastatic UC (T4N0M1). The patient received tislelizumab (200 mg once every 3 weeks) + sunitinib (50 mg/day, administered for 4 weeks with a 2-week interval) for a total of 2 months and died of an advanced tumor in January 2023. In addition, the data of 36 patients with ccRCC and bUC from the literature were analyzed for the present report. The results showed that the median age at first onset was 56.5 years (range, 31-82 years) and the male-to-female ratio was 6:1. Smoking and male sex may be risk factors for this disease, which has a median survival time of 47.5 months. The survival analysis results showed that the pathological stage of bladder cancer may be associated with its prognosis. The present study reviews the potential risks, clinicopathological characteristics and treatment methods of co-occurrence of clear ccRCC and bUC. In conclusion, the high-risk factors for the co-occurrence of ccRCC and bUC were smoking and male sex, and the median survival time was 47.5 months. The pathological stage of bladder cancer may be related to the prognosis.

Using apparent diffusion coefficient maps and radiomics to predict pathological grade in upper urinary tract urothelial carcinoma

BACKGROUND

The apparent diffusion coefficient (ADC) has been reported as a quantitative biomarker for assessing the aggressiveness of upper urinary tract urothelial carcinoma (UTUC), but it has typically been used only with mean ADC values. This study aims to develop a radiomics model using ADC maps to differentiate UTUC grades by incorporating texture features and to compare its performance with that of mean ADC values.

METHODS

A total of 215 patients with histopathologically confirmed UTUC were enrolled retrospectively and divided into training and test sets. The optimum cutoff value for the mean ADC was derived using the receiver operating characteristic (ROC) curve. Radiomics features based on ADC maps were extracted and screened, and then a radiomics model was constructed. Both mean ADC values and the radiomics model were tested on the training and test sets. ROC curve and DeLong test were used to assess the diagnostic performance.

RESULTS

The training set consisted of 151 patients (median age: 68.0, IQR: [63.0, 75.0] years; 80 males), whereas the test set consisted of 64 patients (median age: 68.0, IQR: [61.0, 72.3] years; 31 males). The ADC values were significantly lower in high-grade versus low-grade UTUC (1310 × 10- 6mm2/s vs. 1480 × 10- 6mm2/s, p < 0.001). The area under the curve (AUC) values of the mean ADC values in the training and test sets were 0.698 [95% confidence interval [CI]: 0.625-0.772] and 0.628 [95% CI: 0.474-0.782], respectively. Compared with the mean ADC values, the ADC-based radiomics model, which incorporates features such as log-sigma-1-0-mm-3D_glcm_ClusterProminence and wavelet-LLL_firstorder_10Percentile, obtained a significantly greater AUC in the training set (AUC: 1.000, 95% CI: 1.000-1.000, p < 0.001), and a trend towards statistical significance in the test set (AUC: 0.786, 95% CI: 0.651-0.921, p = 0.071).

CONCLUSIONS

The ADC-based radiomics model showed promising potential in predicting the pathological grade of UTUC, outperforming the mean ADC values in classification accuracy. Further studies with larger sample sizes and external validation are necessary to confirm its clinical utility and generalizability.

CLINICAL TRIAL NUMBER

Not applicable.

Fluorinated chitosan mediated transepithelial delivery of sanguinarine-loaded platinum (IV) prodrug for intravesical instillation therapy of muscle-invasive bladder cancer

Cisplatin-based neoadjuvant chemotherapy is first-line strategy to inhibit progression and metastasis of muscle-invasive bladder cancer (MIBC). However, its clinical efficacy is often limited by drug resistance and severe systemic side effects, highlighting the urgent need for innovative therapeutic approaches. Despite advancements in cisplatin-based regimens, research on intravesical cisplatin delivery systems remains scarce. In this study, we developed an amphiphilic platinum(IV) prodrug micellar platform (Pt (IV)-DI-PEG) capable of efficiently encapsulating sanguinarine (San), which was further coated with fluorinated chitosan (FCS) to construct San@Pt(IV)-DI-PEG@FCS nanoparticles (SPFNPs) for intravesical instillation even targeting MIBC. The resulting SPFNPs demonstrated several advantages: the FCS coating facilitated enhanced trans-epithelial drug delivery by regulating bladder epithelial tight junction proteins, enabling efficient intravesical administration; Second, the glutathione (GSH)-responsive reduction of the Pt(IV) prodrug promoted tumor-targeted release of San and localized accumulation of Pt(II), while simultaneously depleting intracellular GSH. Furthermore, the released San induced reactive oxygen species (ROS) production, oxidative cleavage and inhibit the activation and function of poly (ADP-ribose) polymerase, collectively impairing nucleotide-excision repair and preventing the elimination of Pt-DNA adducts, resulting in persistent DNA damage, cell cycle arrest, and apoptosis in tumor cells. The synergistic effects of San and cisplatin were validated in both orthotopic mouse models and patient-derived orthotopic xenograft, demonstrating robust anti-tumor efficacy. This study underscores the potential of intravesical cisplatin formulations as a promising strategy for MIBC treatment, offering a shift from traditional systemic chemotherapy towards localized, targeted drug delivery systems.

Single-Cell RNA Sequencing Reveals the Tumor Heterogeneity and Immunosuppressive Microenvironment in Urothelial Carcinoma

Urothelial carcinoma (UC) can arise from either the lower urinary tract or the upper tract; they represent different disease entities and require different clinical treatment strategies. A full understanding of the cellular characteristics in UC may guide the development of novel therapies. Here, we performed single-cell transcriptome analysis from four patients with UC of the bladder (UCB), five patients with UC of the ureter (UCU), and four patients with UC of the renal pelvis (UCRP) to develop a comprehensive cell atlas of UC. We found the rare epithelial cell subtype EP9 with epithelial-to-mesenchymal transition (EMT) and cancer stem cell (CSC) features, and specifically expressed SOX6, which was associated with poor prognosis. We also found that ACKR1+ endothelial cells and inflammatory cancer-associated fibroblasts (iCAFs) were more enriched in UCU, which may promote pathogenesis. While ESM1+ endothelial cells may more actively participate in UCB and UCRP tumorigenesis by promoting angiogenesis. Additionally, CD8 + effector T cells were more enriched in UCU and UCRP patients, while Tregs were mainly enriched in UCB tumors. C1QC+ macrophages and LAMP3+ dendritic cells were more enriched in UCB, which is closely related to the formation of the heterogeneous immunosuppressive microenvironment. Furthermore, we found strong interactions between iCAFs, EP9, and Endo_ESM1, and different degrees of activation of the FGF-FGFR3 axis and immune checkpoint pathway were observed in different UC subtypes. Our study elucidated the cellular heterogeneity and the components of the microenvironment in UC arising from the upper and lower urinary tracts and provided novel therapeutic targets.

Predictive Value of the Platelet-Lymphocyte Ratio for Intravesical Recurrence After Radical Nephroureterectomy: A Retrospective Study

Objective

The aim of this study was to evaluate the impact of preoperative platelet lymphocyte ratio (PLR) on the prognosis of patients after radical nephrectomy (RNU).

Methods

We retrospectively analyzed clinical data from 226 patients without a history of bladder cancer who underwent RNU at Beijing Chaoyang Hospital, Capital Medical University between January 2009 and December 2020. Patients were stratified into two groups (A low PLR group (n = 174) and a high PLR group (PLR ≥ 169.4) based on an optimal PLR threshold (PLR=169.4). The predictive accuracy of inflammatory biomarkers was assessed using receiver operating characteristic curves. Univariate and multivariate Cox proportional risk analyses were used to estimate the effect of PLR on intravesical recurrence-free survival (IVRFS), recurrence-free survival (RFS), and overall survival (OS). The effect of PLR on IVRFS, RFS and OS was further examined using Kaplan-Meier survival curve analysis.

Results

The study cohort comprised 226 individuals with a mean age of 67.2 ± 9.8, 113 (50%) males and 113 (50%) females, 68 (30.1%) low-grade tumors and 158 (69.9%) high-grade tumors. In this study, 81 patients (36.7%) relapsed and 73 patients (32.3%) died. The area under the curve for PLR prediction of IVRFS was 0.603, superior to other inflammatory biomarkers. Multivariate analysis showed that PLR > 169.4 independently increased the risk of IVR after RNU, resulting in lower IVRFS [2.028 (1.014-4.057), P = 0.046], RFS [1.900 (1.168-3.090), P = 0.010], and OS [1.866 (1.099-3.167), P = 0.021]. In addition, survival analysis showed lower IVRFS [8.815 (62.722-97.278), P = 0.007], RFS [12.084 (44.315-91.685), P = 0.003] and OS RFS [10.165 (62.077-101.923), P = 0.005] in the low PLR group.

Conclusion

Elevated preoperative PLR is strongly associated with prognosis in patients with upper urothelial carcinoma (UTUC) after RNU without a history of bladder cancer.

The impact of post-nephroureterectomy surgically induced chronic kidney disease on survival outcomes

OBJECTIVE

To investigate the prevalence, predictors and impact of surgically induced chronic kidney disease (CKD-S) on survival outcomes in patients with upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU).

METHODS

Utilising the ROBUUST 2.0 registry, a multicentre retrospective analysis was conducted in patients with UTUC undergoing RNU between 2006 and 2022 who did not have baseline chronic kidney disease (CKD) stages 3-5. We calculated the prevalence of postoperative CKD-S3a (estimated glomerular filtration rate [eGFR] 59-45 mL/min/1.73 m2) and CKD-S3b (eGFR <45 mL/min/1.73 m2) as measured by the Chronic Kidney Disease Epidemiology Collaboration 2021 equation. The analytical cohort was stratified by postoperative CKD stage [no CKD-S [eGFR ≥60 mL/min/1.73 m2]; CKD-S3a [eGFR 59-45 mL/min/1.73 m2] and CKD-S3b [eGFR <45 mL/min/1.73 m2]). The primary outcome was all-cause mortality (ACM). Predictors for development of CKD-S3a/3b and ACM/cancer-specific mortality (CSM) were analysed using logistic and Cox regression, respectively. Kaplan-Meier analysis was used to analyse overall survival (OS) and cancer-specific survival (CSS) among postoperative CKD groups.

RESULTS

We analysed 1862 patients; 34.7% (646) and 39.6% (738), respectively, developed CKD-S3a and CKD-S3b. Predictors of CKD-S3b included increasing age (odds ratio [OR] 1.03, P = 0.029), decreasing preoperative eGFR (OR 1.06, P < 0.001) and receipt of neoadjuvant (OR 2.07, P = 0.006) and adjuvant chemotherapy (OR 1.41, P = 0.012). Worsened ACM was associated with CKD-S3b (hazard ratio 1.42, P = 0.032), but not CKD-S3a (P = 0.766). Development of CKD-S3a (P = 0.812) and CKD-S3b (P = 0.316) were not associated with CSM. The 5-year OS rate was significantly worse in CKD-S3b (no-CKD 71%, CKD-S3a 70%, CKD-S3b 59%; P = 0.017). No differences between CKD-S groups were noted for 5-year CSS (no-CKD 78%, CKD-S3a 77%, CKD-S3b 82%; P = 0.44).

CONCLUSIONS

A significant proportion of UTUC patients undergoing RNU developed CKD-S. Development of CKD-S3b was associated with worse ACM. Increasing age, preoperative eGFR, and chemotherapy were associated with developing CKD-S3b. Our findings call for further exploration and refinement of nephron-preserving surgical strategies and non-nephrotoxic systemic therapy to improve survival outcomes in UTUC.

Clinical, Prognosis, and Treatment Effect Features Analysis of Metachronous and Synchronous UTUC and BUC

OBJECTIVE

To provide a comprehensive understanding of the clinical features of patients with synchronous and metachronous upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BUC) and inform surgical and postoperative adjuvant treatment planning.

PATIENTS AND METHOD

A total of 292 consecutive patients with synchronous and metachronous UTUC-BUC were retrospectively enrolled and were categorized into three groups: (1) UTUC metachronous BUC (N = 185, UTUC-mBUC), (2) BUC-metachronous UTUC (N = 43, BUC-mUTUC), (3) synchronous UTUC-BUC (N = 64, sUTUC-BUC). We compared pathological characteristics and survival data among groups with Wilcoxon's rank sum tests, Pearson's chi-squared, and the Kaplan-Meier method.

RESULTS

In the sUTUC-BUC group, a higher proportion of patients exhibited UTUC tumors with grade G3 (56%, P = .001) and stage T4 (6%, P < .001) than group UTUC-mBUC (G3 = 16%, T4 = 0%). The proportion of patients with variant histology subtype in group sUTUC-BUC was higher than that of metachronous UTUC-BUC, involving squamous (P = .003), adenoid (P = .012), and sarcomatoid (P < .001) differentiation. It was also observed that the maximum diameter of the UTUC tumor of group sUTUC-BUC (median = 3.5) was significantly larger than group UTUC-mBUC (median = 2.5, P = .002) and group BUC-mUTUC (median = 2.2, P < .001). Notably, sUTUC-BUC has an increased risk of cancer-specific death compared with UTUC-mBUC (P < .001) and BUC-mUTUC (P < .001). On multivariable Cox regression, synchronous UTUC-BUC was an independent predictor of both RFS (P < .001; vs. UTUC-mBUC: HR 0.555, P = .004; vs. BUC-mUTUC: HR 0.279, P < .001) and CSS (P < .001, HR 29.737). Moreover, sUTUC-BUC showed a better response to intravesical therapy and chemotherapy with higher cancer-specific survival (P < .001) and recurrence-free survival (P = .034).

CONCLUSIONS

The prognosis and pathological characteristics among different metachronous and synchronous UTUC and BUC were diverse. The synchronous UTUC-BUC group showed variant histology subtype, high-grade tumors, advanced tumors, multifocal UTUC, worse cancer-specific survival, but better response to intravesical therapy and chemotherapy.

Preoperative Plasma Insulin-Like Growth Factor-I and Its Binding Proteins-Based Risk Stratification of Patients Treated With Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

INTRODUCTION

We evaluate the predictive and prognostic value of insulin-like growth factor-I (IGF-1), IGF binding protein-2 (IGFBP-2) and -3 (IGFBP-3) in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

METHODS

This is a retrospective analysis of a multi-institutional database comprising 753 patients who underwent RNU for UTUC and had a preoperative plasma available. Logistic and Cox regression analyses were performed. The discriminative ability and clinical utility of the models was calculated using the lasso regression test, area under receiver operating characteristics curves, C-index, and decision curve analysis (DCA).

RESULTS

Lower preoperative plasma levels of IGFBP-2 and -3 independently correlated with increased risks of lymph node metastasis, pT3/4 disease, nonorgan confined disease, and worse recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) (all P ≤ .004). The addition of both IGFBP-2 and -3 to a postoperative multivariable model, that included standard clinicopathologic characteristics, improved the model's concordance index by 10%, 9%, and 8% for RFS, CSS, and OS, respectively. On DCA, addition of both IGFBP-2 and -3 to base models improved their performance for RFS, CSS, and OS by a statistically and clinically significant margin. Plasma IGF-1 was not associated with any of outcomes.

CONCLUSIONS

We confirmed that a lower plasma levels of IGFBP-2 and -3 both are independent and clinically significant predictors of adverse pathological features and survival outcomes in UTUC patients treated with RNU. These findings might help guide the clinical decision-making regarding perioperative systemic therapy and follow-up scheduling.

Development and Validation of a Multivariable Nomogram Predictive of Post-Nephroureterectomy Renal Function

BACKGROUND AND OBJECTIVE

The timing of perioperative nephrotoxic chemotherapy for upper tract urothelial carcinoma (UTUC) remains controversial and strongly depends on predicted platinum eligibility after radical nephroureterectomy (RNU). The study objective was to develop and validate a multivariable nomogram to predict estimated glomerular filtration rate (eGFR) following RNU.

METHODS

This was a multi-institutional retrospective study of patients with UTUC treated with RNU from 2000 to 2020 at seven high-volume referral centers. Use of adjuvant chemotherapy was risk-stratified. Patients were retrospectively randomly allocated 2:1 to discovery and validation cohorts. Discovery data were used to identify independent factors associated with GFR at 1-3 mo after RNU on linear regression, and backward selection was applied for model construction. Accuracy was defined as the percentage of predicted eGFR results within 30% of the corresponding observed eGFR.

KEY FINDINGS AND LIMITATIONS

We included 1100 patients, of whom 733 were in the discovery and 367 were in the validation cohort. Multivariable predictors of postoperative eGFR decline included advanced age (odds ratio [OR] -0.18, 95% confidence interval [CI] -0.28 to -0.08), diabetes (OR -2.38, 95% CI -4.64 to -0.11), and hypertension (OR -2.24, 95% CI -4.16 to -0.32). Factors associated with favorable postoperative eGFR included larger tumor size (OR 10.57, 95% CI 7.4-13.74 for tumors >5 cm vs ≤2 cm) and preoperative eGFR (OR 0.44, 95% CI 0.39-0.49). A composite nomogram predicted postoperative eGFR with good accuracy in both the discovery (80.5%) and validation (78.6%) cohorts. Limitations include exclusion of patients who received neoadjuvant chemotherapy.

CONCLUSIONS

A nomogram that incorporates ubiquitous preoperative clinical variables can predict post-RNU eGFR and was validated with an independent cohort.

PATIENT SUMMARY

We developed a tool that uses patient data to predict eligibility for chemotherapy after surgery to remove the kidney and ureter in patients with cancer in the upper urinary tract.

Efficacy and safety of adjuvant nivolumab after radical surgery for high-risk urothelial carcinoma: a preliminary report of real-world data from a single institution

BACKGROUND

The phase 3 CheckMate 274 trial demonstrated superiority of adjuvant nivolumab over placebo after radical surgery in patients with high-risk urothelial carcinoma (UC). However, real-world data on the efficacy and safety profile of adjuvant nivolumab in Japan have not been reported.

METHODS

This retrospective study enrolled patients with high-risk UC who received adjuvant nivolumab therapy following radical surgery between 2022 and 2024 at our institution. We evaluated immune-related adverse events (irAEs) according to the Common Terminology Criteria for Adverse Events, version 5.0. Kaplan-Meier curves were used to assess disease-free survival (DFS) and overall survival (OS).

RESULTS

Thirty-three patients with high-risk UC receiving adjuvant nivolumab therapy following radical surgery were identified, and median follow-up was 11 months. Three patients experienced grade 3 irAEs, and 8 discontinued adjuvant nivolumab therapy due to irAEs. No grade 4 or 5 irAEs were observed. Eight patients have completed 1 year of treatment, and nine are currently on treatment. Nine patients had recurrences and one died of cancer. Of the nine patients with recurrences, six relapsed while on adjuvant nivolumab therapy, two relapsed after completing 1 year of treatment, and one relapsed after discontinuation of irAE. The 1- and 2-year OS rates were 100% and 90%, respectively, and median OS was not reached. The 1- and 2-year DFS rates were 70% and 60%, respectively, and median DFS was 26 months.

CONCLUSIONS

Adjuvant nivolumab appears to have some efficacy in Japanese patients. Since this is a postoperative adjuvant therapy, careful patient selection is warranted.

Exploring Radiotherapy as a Promising Alternative for Managing Advanced Upper Tract Urothelial Carcinoma: Rescuing Chemotherapy-Intolerant Patients

PURPOSE

To investigate the safety and effectiveness of radiotherapy for advanced upper tract urothelial carcinoma (UTUC) patients intolerant to chemotherapy.

METHODS

Data for 21 patients with advanced UTUC intolerant to chemotherapy were retrospectively collected. All patients were treated with conventionally fractionated radiotherapy (50-70 Gy/20-33 f) or partial-SABR boost to the lesions (50-60 Gy/20-25 f with tumor center boosted with 6-8 Gy/f, 3-5 f) for bulky tumors.

RESULTS

The median age was 75 years (range, 58-87 years). Primary tumor resection was performed for all patients and none underwent metastatic resection. Seventeen (81%) patients had oligometastasis (1-5 metastases) at diagnosis. Eighteen (85.7%) received irradiation to all tumor lesions. Lymph node metastasis was predominant in the whole group (17/21). Other lesions were distributed as local recurrence (7/21), bone metastases (2/21) and abdominal wall/muscle (2/21). The median follow-up time was 38.5 months (interquartile range, 15.2-48.7 months). Rate of local control (LC), progression-free survival (PFS) and overall survival (OS) of the whole group at 1 year were 90%, 46.6%, and 80.4%, respectively. At 3 years, LC, PFS and OS were 65.6%, 26.6%, and 40.9%, respectively. Fourteen patients developed acute mild gastrointestinal toxicity, generally of grade 1-2; 8 patients developed acute grade 1-2 hematological toxicity, consisting mainly of anemia and leukopenia. No grade 3 or higher acute or late toxicities were observed.

CONCLUSION

For patients with advanced UTUC who are not able to tolerate chemotherapy, radiotherapy is a safe treatment and can achieve good local tumor control.

Incidence of Proteinuria Post Radical Nephrectomy in Comparison to Partial Nephrectomy: A Comparative Study

Objectives The objective of this study is to enhance understanding of the incidence and impact of proteinuria following nephrectomy, to guide clinical decision-making, and to optimize post-operative monitoring strategies. Specifically, the study seeks to compare the incidence of proteinuria in patients undergoing radical nephrectomy and those receiving partial nephrectomy, thereby contributing valuable insights into post-surgical outcomes that could inform treatment approaches and improve patient care. Methods It is a retrospective cohort design, analyzing clinical data from patients who underwent radical or partial nephrectomy in King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, between 2014 and 2022. Data was entered in Excel (Microsoft Corporation, Redmond, Washington, United States) and analyzed in IBM SPSS Statistics for Windows, Version 29.0 (Released 2023; IBM Corp., Armonk, New York, United States). Results There was a total of 310 participants, predominantly male (n=167, 53.9%), with radical nephrectomy (n=188, 60.6%) being more common than partial (n=99, 31.9%). Post surgery, a significant decline in estimated glomerular filtration rate (eGFR) was noted in radical nephrectomy at one to three months (73.09 mL/minute) compared to partial nephrectomy (90.99 mL/minute) (p<0.001), with similar trends at 6-12 months. The mortality rate was low at 1.6% (n=5), with significant associations between preoperative eGFR and mortality (p=0.008). Proteinuria post operation was observed in 27.1% (n=84), with significant differences in proteinuria levels between radical (107.10 mg/dL) and partial nephrectomy (62.80 mg/dL) (p=0.031). Conclusion Our study found that radical nephrectomy was more common and associated with a greater decline in postoperative eGFR compared to partial nephrectomy. Proteinuria was significantly higher in radical nephrectomy patients, and preoperative eGFR was linked to mortality risk, highlighting the need for careful monitoring in high-risk individuals.

Clinicopathological risk factors associated with tumor relapse of upper tract urothelial carcinoma after radical nephroureterectomy: A single institution 20-year experience

Upper tract urothelial carcinoma (UTUC) is a relatively rare yet aggressive malignancy. While radical nephroureterectomy (RNU) remains the cornerstone treatment, UTUC has high local and metastatic relapse rates, leading to a dismal prognosis. To identify the clinicopathological factors associated with an increased risk of local and metastatic relapse in UTUC, we conducted a retrospective analysis of 133 consecutive UTUC patients who underwent RNU from 1998 to 2018. Patients lost to follow-up or with a history of bladder cancer were excluded from the study. The remaining 87 patients were categorized into two subgroups: those with tumor recurrence/relapse (40 cases) and those without recurrence/relapse (47 cases). Clinical and pathological characteristics were compared across the two groups. Multiple factors are associated with UTUC recurrence/relapse including larger tumor size, histology divergent differentiations/subtypes, high tumor grade, advanced pathologic T stage, positive margin, lymphovascular invasion (LVI), positive lymph node status, and preoperative hydronephrosis. Multivariate Cox regression analysis revealed that squamous differentiation predicted recurrence/relapse (p = 0.012), independent of tumor stage. Moreover, compared to the conventional histology type, UTUC with squamous differentiation had a significantly higher relapse rate (p = 0.0001) and poorer survival (p = 0.0039). This observation was further validated in invasive high-grade UTUC cases. Our findings suggest that many pathological factors contribute to UTUC recurrence/relapse, particularly, squamous differentiation may serve as an independent risk predictor for relapse and a potent prognosticator for adverse cancer-specific survival in UTUC patients. Recognizing and thoroughly assessing the pathological factors is essential for better oncologic management of UTUC.

Developing a Novel Prognostic Model Based on Muscle-Invasive Bladder Cancer Types: A Multicenter Retrospective Cohort Study of Patients Who Received Radical Cystectomy and Chemotherapy

BACKGROUND

To develop a prognostic model to manage patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC) and chemotherapy.

PATIENTS AND METHODS

Clinicopathologic characteristics and survival data were collated from a North American database to develop a model. Genomic and clinicopathologic data were also obtained from European and Asian databases to externally validate the model. Patients were classified as either "primary" or "progressive" MIBC according to non-muscle invasive stage history. Optimized cancer-specific survival (CSS) models, based on MIBC types, were constructed using Cox's proportional hazard regression. Differences of biological function and tumor immunity, between two risk-based groups stratified according to the prognostic model, were estimated.

RESULTS

There were 2631 participants in the American cohort, 291 in the European cohort and 142 in the Asian cohort. Under Cox's regression analysis, tumor stage, lymph node stage, age, ethnicity, and MIBC types were independent CSS predictors (all p < 0.05). The constructed nomogram, which integrated these variables, improved the predictive power. This model had good discrimination and calibration. Patients were categorized into high- or low-risk groups according to the total points calculated. Kaplan-Meier curves revealed that patients in the high-risk group had poorer survival (p < 0.001). This was confirmed with two external validation cohorts (both with p < 0.001). Higher stromal scores and increased M0 and M2 macrophage numbers were observed in samples from the high-risk group, whereas regulatory T cells had lower infiltration in these populations (all with p < 0.05).

CONCLUSIONS

This MIBC type-based nomogram provides accurate CSS predictions, which could help improve patient management and clinical decision-making.

Profiling Fibroblast Growth Factor Receptor 3 Expression Based on the Immune Microenvironment in Upper Tract Urothelial Carcinoma

BACKGROUND

Although several studies have shown favorable outcomes in upper tract urothelial carcinoma (UTUC) with fibroblast growth factor receptor 3 (FGFR3) mutations and/or expression, the relationship between immune cell markers and FGFR3 expression remains unknown.

OBJECTIVE

To clarify the FGFR3-based immune microenvironment and investigate biomarkers to predict the treatment response to pembrolizumab (Pem) in patients with UTUC.

DESIGN, SETTING, AND PARTICIPANTS

We conducted immunohistochemical staining in 214 patients with UTUC. The expression levels of FGFR3, CD4, CD8, CD68, CD163, CD204, and programmed cell death ligand 1 (PD-L1) were examined.

INTERVENTION

All UTUC patients underwent radical nephroureterectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We assessed the relationship between these immune markers and patient prognosis.

RESULTS AND LIMITATIONS

A total of 109 (50.9%) patients showed high FGFR3 expressions and a favorable prognosis compared with the remaining patients. Among the six immune markers, CD8 high expression was an independent favorable factor, whereas CD204 expression was an independent prognostic factor for cancer death. From the FGFR3-based immune clustering, three immune clusters were identified. Cluster A showed low FGFR3 with tumor-associated macrophage-rich components (CD204+) followed by a poor prognosis due to a poor response to Pem. Cluster B showed low FGFR3 with an immune hot component (CD8+), followed by the most favorable prognosis owing to a good response to Pem. Cluster C showed high FGFR3 expression but an immune cold component, followed by a favorable prognosis due to the high FGFR3 expression, but a poor response was confirmed with Pem.

CONCLUSIONS

Although most patients exhibit a poor response to Pem, individuals with low FGFR3 expression and immune hot status may benefit clinically from Pem treatment.

PATIENT SUMMARY

We conducted immunohistochemical staining to evaluate fibroblast growth factor receptor 3 (FGFR3)-related immune microenvironment by evaluating the expressions of CD4, CD8, CD68, CD163, CD204, and PD-L1 in 214 upper tract urothelial carcinoma patients. We identified three distinct immune clusters based on FGFR3 expressions and found that patients with a low FGFR3 expression but immune hot status received the maximum benefit from an immune checkpoint inhibitor.

The role of intravesical chemotherapy following nephroureterectomy in upper tract urothelial carcinoma: A systematic review and meta-analysis

INTRODUCTION

Intravesical recurrence of upper tract urothelial carcinoma after radical nephroureterectomy occurs in 22% to 47%. Intravesical chemotherapy is still underused due to concerns about its efficacy and safety. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of intravesical chemotherapy regimens in reducing the risk of intravesical recurrence following radical nephroureterectomy.

MATERIALS AND METHODS

A literature search was conducted using PubMed/Medline, Embase, and Web of Science databases to identify reports published until March 2024. The PRISMA guidelines were followed to identify eligible studies. The outcomes measured were intravesical recurrence rates and complications in patients treated with different intravesical instillation chemotherapy and timing after radical nephroureterectomy. Sub-analyses were performed on randomized controlled trials and studies involving patients with no history of bladder cancer.

RESULTS

Eighteen studies met our inclusion criteria, and data from 2,483 patients were reviewed. Intravesical chemotherapy significantly reduced the risk of intravesical recurrence at 12 months (OR = 0.46; 95% CI: 0.33-0.65; P < 0.001;) and at 24 months (OR = 0.41, 95% CI: 0.28-0.61; P < 0.001). Notably, no association was found when confronting intra and postoperative instillations (OR = 0.66; 95% CI: 0.34-1.28; P = 0.2), nor single vs. multiple instillation (OR = 1.37; 95% CI: 0.75-2.50; P = 0.3). The pooled rate for minor and major complications was 9% and 0.9%, respectively.

CONCLUSION

This study demonstrates that intravesical chemotherapy significantly reduces intravesical recurrence rates after radical nephroureterectomy at 12 and 24 months. Additionally, it underscores the favorable safety profile of intravesical chemotherapy, with a low incidence of major complications. The ideal instillation scheme and chemotherapy agent should be further defined.

Urinary calculi successfully expelled in a patient through traditional Chinese exercise: A case report

RATIONALE

Urinary calculi are hard mineral deposits that typically require medication or surgery, such as lithotripsy. This case report presents traditional Chinese exercises (TCEs) as a potential alternative for stone expulsion.

PATIENT CONCERNS

A 41-year-old male with no history of urinary tract stones, experienced sudden severe lower back and abdominal pain accompanied by nausea and vomiting.

DIAGNOSIS

Computed tomography scan revealed a small calculus at the distal end of the left ureter (within the bladder wall), approximately 2 mm in size, with mild hydronephrosis in the ureter and renal pelvis.

INTERVENTIONS

The patient was initially prescribed medication for pain relief and was advised to engage in TCEs.

OUTCOMES

Follow-up computed tomography scan after the exercise regimen showed complete expulsion and disappearance of the urinary calculi. The patient reported significant improvement in physical and mental health with no recurrence of calculi observed in subsequent checkups.

LESSONS

This case suggests that TCEs may facilitate the expulsion of small urinary calculi, offering a noninvasive treatment option. Further research is needed to confirm the therapeutic effects of TCEs on urinary calculi and to explore its potential mechanisms.

Urothelial carcinoma of the renal pelvis with squamous and sarcomatoid differentiation complicated by hydronephrosis and pyelonephritis: a case report and literature review

BACKGROUND

Renal pelvic urothelial carcinoma with multiple histological variants co-occurs with hydronephrosis and pyelonephritis extremely rarely. The diagnosis of renal pelvic urothelial carcinoma can be complicated by these conditions, leading to delayed or missed diagnosis or misdiagnosis.

CASE PRESENTATION

We report the evolutionary course of a rare case of renal pelvic urothelial carcinoma containing squamous and sarcomatoid differentiation associated with hydronephrosis and pyelonephritis in a low-functioning kidney. Preoperative clinical and imaging manifestations were highly suggestive of hydronephrosis and pyelonephritis; however, all corresponding therapeutic measures failed. Eventually, nephrectomy was performed, and postoperative pathological examination revealed renal pelvic urothelial carcinoma with squamous and sarcomatoid differentiation. Further residual ureter and bladder cuff resection was refused by the patient. Regular cisplatin-based postoperative chemotherapy and bladder perfusion were arranged, and cystoscopy and imaging examinations were performed regularly for follow-up.

CONCLUSION

Hydronephrosis and pyelonephritis can mask the typical clinical and imaging manifestations of renal pelvic urothelial carcinoma. Renal pelvic malignancy should be considered in patients with intractable pyelonephritis and hydronephrosis. There is no standard treatment for renal pelvic carcinoma with multiple pathological types. Radical surgery is considered an appropriate option and should be performed as early as possible. Chemotherapy and immunotherapy may improve patient survival.

Chronic renal impairment predicts oncological outcomes in UTUC patients undergoing RNU

OBJECTIVE

This study aims to explore the relationship between pre-existing renal impairment and oncological outcomes in upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU) using data from a multicentre international registry.

PATIENTS AND METHODS

Data on non-metastatic UTUC patients who underwent RNU were obtained from the Clinical Research Office of the Endourology Society Urothelial Carcinomas of the Upper Tract (CROES-UTUC) Registry. Patients were categorised into normal pre-operative renal function and chronic renal impairment (CKD) groups, with CKD defined as an estimated glomerular filtration rate below 60 mL/kg/1.73 m². Kaplan-Meier survival analysis was employed to investigate disease-free survival (DFS) and overall survival (OS). Multivariable Cox regression analysis was conducted to identify confounding variables.

RESULTS

A total of 1393 patients diagnosed with UTUC who underwent RNU between 2014 and 2019 were analysed. 875 patients (62.4%) had normal renal function, whilst 528 patients (37.6%) had CKD prior to RNU. The two groups had similar proportions of bladder cancer history, comparable cardiovascular comorbidity, similar tumour stage, and comparable proportions receiving laparoscopic or robotic-assisted RNU. In multivariable cox regression analysis, CKD was found to be associated with inferior DFS (HR = 1.419; 95%CI = 1.060-1.898; p = 0.019). Upon multivariable analysis, pre-existing renal impairment and higher T stage (HR = 4.613; 95%CI = 1.829-4.712; p < 0.001) and the use of adjuvant chemotherapy (HR = 1.858; 95%CI = 1.229-2.807; p = 0.003) were also found to associate with worse DFS. Significant cardiovascular disease and higher T stage were associated with worse OS. Existing renal impairment at baseline did not have any significant associated with OS.

CONCLUSION

In this multicentre registry, preoperative chronic renal impairment was identified as an independent predictor of inferior DFS in patients undergoing RNU for non-metastatic UTUC. Preoperative CKD could serve as a clinical predictor of poorer oncological outcomes.

Gold standard nephroureterectomy, chemoprophylaxis and surveillance in upper tract urothelial carcinoma

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence on surgical management, strategies to reduce tumor recurrence, and surveillance regimens in patients diagnosed with upper tract urothelial carcinoma (UTUC) and elected for radical treatment.

RECENT FINDINGS

Minimally invasive surgery is gaining momentum in the surgical management of UTUC. Chemoprophylaxis is still the gold standard to reduce intravesical recurrence after radical nephroureterectomy (RNU). Novel surveillance strategies have been proposed to adapt follow-up regimens to patients' characteristics.

SUMMARY

Minimally invasive surgery has been associated with comparable oncological outcomes to the open approach while improving postoperative morbidity. In these cases, bladder cuff excision (BCE) is mostly performed by an extravesical approach, that demonstrates a noninferiority compared to the intravesical one in terms of oncological outcomes. Although lymphadenectomy is recommended in patients with high-risk tumors, its benefits are still unclear. Currently, there is a lack of recent prospective trials on chemoprophylaxis to reduce intravesical recurrence post RNU, making single-dose postoperative chemotherapy instillation the standard treatment. Although novel risk stratification models were released by international urological guidelines, their validity is mainly nonevidence-based. Risk-adapted follow-up strategies incorporating cystoscopy and cross-sectional imaging accounting for individual patient factors should be implemented.

Kidney-Sparing Management of UTUC in Solitary Kidney Patients: A Retrospective Analysis and Narrative Review

Background/Objectives: The aim of this study is the presentation of an endoscopic therapeutic approach for three patients with a solitary kidney who were diagnosed with urothelial cancer of the upper tract. Methods: This retrospective analysis included patients with solitary kidneys who suffered from high-grade UTUC (urothelial cancer of the upper urinary tract) and underwent conservative treatment. Results: The first patient was a 67-year-old male who had a prior history of a nephroureterectomy due to UTUC six years ago. The patient was diagnosed with high-grade UTUC in the contralateral kidney. The tumor has been managed with endoscopic ablation. The second patient was a 74-year-old male with a non-functional kidney and high-grade UTUC diagnosed in the contralateral side. The patient underwent endoscopic ablation for the tumor. The third case was a 68-year-old female patient who had a history of a nephroureterectomy due to UTUC. Afterward, she was diagnosed with high-grade UTUC in the contralateral kidney. The patient was treated with percutaneous tumor resection and the placement of a nephrostomy tube. The first patient was included in an immunotherapy program based on an oncologist consultation after laser ablation treatment for Ta high-grade UTUC, followed by the endoscopic management of two recurrences. Afterward, no recurrence was detected. The remaining two patients followed up without the detection of a new recurrence. Conclusions: The kidney-sparing approach (tumor laser ablation or resection) for high-risk UTUC treatment in selected patients with solitary kidneys seems to provide adequate early outcomes in relation to preserving renal function and effective disease management. It is important to personalize the way of treatment in every case after a thorough examination of the patient's data.

Case report: Radical robotic nephroureterectomy after chemotherapy followed by avelumab in a patient with node-positive UTUC

Introduction

Platinum-based chemotherapy followed by the immune checkpoint inhibitor avelumab represents an intensified upfront therapy regimen that may result in significant downstaging and, subsequently, potentially radical robotic nephroureterectomy with a lymph node dissection, an uncommon approach with an unexpectedly favorable outcome.

Case presentation

We report a case of a 70-year-old female presented with a sizeable cN2+ tumor of the left renal pelvis and achieved deep partial radiologic response after systemic therapy with four cycles of gemcitabine-cisplatin chemotherapy followed by avelumab maintenance therapy and subsequent robotic resection of the tumor. The patient continued with adjuvant nivolumab therapy once recovered after surgery and remained tumor-free on the subsequent follow-up. The systemic treatment was without any severe adverse reaction.

Conclusion

We highlight the feasibility of the upfront systemic therapy with four cycles of gemcitabine-cisplatin chemotherapy followed by avelumab maintenance, robotic-assisted removal of the tumor, and adjuvant immunotherapy with nivolumab. This intensification of the upfront systemic therapy, and the actual treatment sequence significantly increase the chances of prolonged survival or even a cure. This type of personalized therapeutic approach can accelerate future advanced immunotherapeutic strategies.

Perirenal Fat CT Radiomics-Based Survival Model for Upper Tract Urothelial Carcinoma: Integrating Texture Features with Clinical Predictors

Background: Upper tract urothelial carcinoma (UTUC) presents significant challenges in prognostication due to its rarity and complex anatomy. This study introduces a novel approach integrating perirenal fat (PRF) radiomics with clinical factors to enhance prognostic accuracy in UTUC. Methods: The study retrospectively analyzed 103 UTUC patients who underwent radical nephroureterectomy. PRF radiomics features were extracted from preoperative CT scans using a semi-automated segmentation method. Three prognostic models were developed: clinical, radiomics, and combined. Model performance was assessed using concordance index (C-index), time-dependent Area Under the Curve (AUC), and integrated Brier score. Results: The combined model demonstrated superior performance (C-index: 0.784, 95% CI: 0.707-0.861) compared to the radiomics (0.759, 95% CI: 0.678-0.840) and clinical (0.653, 95% CI: 0.547-0.759) models. Time-dependent AUC analysis revealed the radiomics model's particular strength in short-term prognosis (12-month AUC: 0.9281), while the combined model excelled in long-term predictions (60-month AUC: 0.8403). Key PRF radiomics features showed stronger prognostic value than traditional clinical factors. Conclusions: Integration of PRF radiomics with clinical data significantly improves prognostic accuracy in UTUC. This approach offers a more nuanced analysis of the tumor microenvironment, potentially capturing early signs of tumor invasion not visible through conventional imaging. The semi-automated PRF segmentation method presents advantages in reproducibility and ease of use, facilitating potential clinical implementation.

Comparison of surgical effectiveness: kidney sparing surgery for upper tract urothelial carcinoma

PURPOSE OF REVIEW

This review provides an overview of the recent publications on kidney-sparing-surgery (KSS) for upper tract urothelial carcinoma (UTUC), an alternative to radical nephroureterectomy (RNU) for an increasing number of indications.

RECENT FINDINGS

Recent studies highlight comparable survival outcomes between KSS [ureterorenoscopy with tumour ablation (URS) or segmental ureteral resection (SUR)] and RNU, even in high-risk UTUC patients. KSS has shown to preserve renal function without significantly compromising oncologic control in appropriately selected patients. Included literature also researched surgical complications, surveillance strategies, such as second-look ureteroscopy, and comparative cost analyses.

SUMMARY

Over the past two and a half years, studies have emphasized the growing usage of URS and SUR in treating selected UTUC patients. Recent literature has remarkably included relatively large numbers of typically high-risk patients with features such as high-grade tumours, stage >Ta, multifocality, and hydronephrosis with acceptable results. Further research should expand on the different indications for KSS, its postoperative surveillance and comparative economic analyses.

Robotic surgery of the urothelial carcinoma of the upper urinary tract single surgeon initial experience, 66 consecutive cases

PURPOSE

Robotic surgery is increasingly utilized in the treatment of urothelial carcinoma of the upper urinary tract (UTUC). This study investigates the advantages and burden of robot-assisted surgical treatment of the urothelial carcinoma of the upper urinary tract in a referral urological department, along with their functional and oncological results.

METHODS

The study included 66 prospectively enrolled patients who were surgically treated by a single, robotically specialized surgeon between July 2019 and December 2023. Patients were divided into three groups. Group 1: 50 patients underwent robot-assisted radical Nephroureterectomy (RANU) with bladder cuff excision, Group 2: 11 patients underwent RANU simultaneously with robot-assisted radical cystectomy (RARC), and Group 3: 5 patients underwent robot-assisted segmental ureterectomy (RASU). Clinical and oncological parameters were compared. Perioperative morbidity according to Clavien-Dindo was the primary endpoint of our study. The secondary endpoint was oncologic outcomes.

RESULTS

37.8% of patients had locally advanced carcinomas. The average console time of RANU with bladder cuff excision was 69 min. The rate of positive surgical margins was n = 1/66 (2%). Lymphadenectomy (LAD) was performed on 30% of patients, with a mean of 13.7 lymph nodes removed. Of those who received LAD, 33% had lymph node metastasis. n = 6/66 (9%) patients received blood transfusion. The overall complication rate was 24%. The readmission rate was 7.5%. With a median follow-up of 26 months, the 2-year recurrence-free survival rate was 84.4%, and the 2-year overall survival rate was 94%.

CONCLUSION

Robotic surgery is a feasible option for treating UTUC that can be adapted to meet the surgical needs of each patient. Prospective studies are warranted to confirm its benefits.

Hereditary and Familial Traits in Urological Cancers and Their Underlying Genes

Early recognition of hereditary urological cancers may influence diagnostic and therapeutic decision-making, and potentially alter the fate of patients and family members. Here, we introduce readers to the current knowledge on germline genetic testing and clinical practice in prostate, bladder, renal, and testicular carcinoma. Considering all urological cancer patients, routine inquiries about familial cancer history should become a standard practice in clinical settings. If suspicion arises, patients can opt for two avenues: referral to genetic counseling or undergoing genetic tests after consultation with the treating urologist.

Patient summary

Tumors of the urogenital tract (prostate, kidney, bladder, and testes) can sometimes be related to genetic mutations that are present in all the cells of the body. Such mutations can be inherited and run in families. Therefore, it is relevant to obtain information on the incidence of all cancers in the family history. The information obtained may initiate genetic testing, leading to the identification of mutations that are related to cancer in the current or next generation. In addition, these mutations may offer alternative treatment options for patients.

Genetic Alterations in Chromatin Regulatory Genes in Upper Tract Urothelial Carcinoma and Urothelial Bladder Cancer

PURPOSE

Upper tract urothelial carcinoma (UTUC) and urothelial carcinoma of the bladder (UCB) share histomorphological and therapeutic features but distinct epidemiologic and clinicopathologic characteristics. We examined alterations of chromatin regulatory genes in molecular subtypes, clonal relatedness, and T-cell receptor (TCR) diversity in UTUC and UCB.

MATERIALS AND METHODS

Targeted next-generation sequencing or whole-exome DNA sequencing and TCR sequencing were conducted with 34 UTUC and 49 UCB specimens from 63 patients. Tumors were subtyped based on the expression of CK5 and GATA3. Results of tissue microarray of 78 muscle-invasive bladder cancer (MIBC) samples were used as prognostic factors of different subtypes of MIBC.

RESULTS

Chromatin regulatory genes were frequently mutated in both UTUC and UCB. Rapid relapse and progression of non-MIBC are correlated with alterations of KMT2C and EP300. Frequency of alterations in chromatin regulatory genes is higher in UTUC patients with SBS22 and SBS2 signatures and lower in UCB patients with SBS2 and SBS6 signatures. GATA3 and CK5 double-positive patients with higher frequencies of SMARCA4, ARID1A, and EP300 mutations have better prognoses than patients with basal subtypes. Although UTUC and UCB in the same patient can be either clonally related or developed independently, mutated genes in chromatin pathway were enriched in the related clones. Compared to UTUC, UCB had more deleterious mutations in DNA damage repair (DDR) genes, higher levels of tumor mutation burden (TMB) and copy number variations (CNVs), as well as higher TCR clonality and lower TCR diversity.

CONCLUSIONS

Since genetic alterations of the chromatin pathway genes are important in both UTUC and UCB, they could serve as potential biomarkers for predicting disease progression and therapeutic targets. Differences in mutation frequencies of DDR pathway, TMB, CNV, and TCR might be the contributing factors for the distinct responses to immune checkpoint inhibitor (ICI) between UTUC and UCB.

A collaborative review of the microsatellite instability/deficient mismatch repair phenotype in patients with upper tract urothelial carcinoma

OBJECTIVE

To perform a collaborative review of the literature exploring the microsatellite instability/deficient mismatch repair (MSI/dMMR) phenotype in patients with upper tract urothelial carcinoma (UTUC).

METHOD

A collaborative review of the literature available on Medline was conducted by the Cancer Committee of the French Association of Urology to report studies describing the genetic mechanisms, investigation, prevalence and impact of the MSI/dMMR phenotype in UTUC patients.

RESULTS

The predominant genetic mechanism leading to the MSI/dMMR phenotype in UTUC patients is related to the constitutional mutation of one allele of the MMR genes MLH1, MSH2, MSH6 and PMS2 within Lynch syndrome. Indications for its investigation currently remain limited to patients with a clinical suspicion for sporadic UTUC to refer only those with a positive testing for germline DNA sequencing to screen for this syndrome. With regard to technical aspects, despite the interest of MSIsensor, only PCR and immunohistochemistry are routinely used to somatically investigate the MSI and dMMR phenotypes, respectively. The prevalence of the MSI/dMMR phenotype in UTUC patients ranges from 1.7% to 57%, depending on the study population, investigation method and definition of a positive test. Younger age and a more balanced male to female ratio at initial diagnosis are the main specific clinical characteristics of UTUC patients with an MSI/dMMR phenotype. Despite the conflicting results available in the literature, these patients may have a better prognosis, potentially related to more favourable pathological features. Finally, they may also have lower sensitivity to chemotherapy but greater sensitivity to immunotherapy.

CONCLUSION

Our collaborative review summarises the available data from published studies exploring the MSI/dMMR phenotype in UTUC patients, the majority of which are limited by a low level of evidence.

Prognostic impact of tumor size in ureteral cancer following segmental ureterectomy

OBJECTIVE

To evaluate the classification and prognostic effects of a 2 cm tumor size in patients with ureteral cancer (UC) undergoing segmental ureterectomy (SU).

PATIENTS AND METHODS

A total of 75 patients with UC who underwent SU in our hospital between April 2013 and April 2023 were included in this study. The study population was grouped based on tumor size, which was defined as the maximum diameter of the pathological specimens, resulting in 30 patients (40.0%) with tumor size <2 cm and 45 patients (60.0%) with tumor size ≥2 cm. The clinicopathological variables, perioperative parameters, and oncological outcomes were compared between the 2 groups. The endpoints were recurrence-free survival (RFS), and cancer-specific survival (CSS).

RESULTS

A tumor ≥2 cm was related to a higher positive rate of urine exfoliative cytology (P = 0.049) and fewer preoperative ureteroscopies (P = 0.033) than tumors <2 cm. After a follow-up of 6.3 to 128.7 months (median 40.2 months), 23 cases (30.7%) experienced recurrence and 11 patients (14.7%) succumbed to UC in the end. Compared to those with tumor size <2 cm, patients with tumor size ≥2 cm experienced more urothelial recurrence (P = 0.032). Kaplan-Meier analysis demonstrated that patients with tumor size ≥2 cm displayed inferior urothelial RFS than those with tumor size <2 cm (P = 0.026). Multivariate Cox analysis identified tumor size ≥2 cm, and pathological stage ≥T2 were significant prognostic factors of poor urothelial RFS (all P < 0.05).

CONCLUSION

Tumor size ≥2 cm was associated with a high rate of urothelial recurrence and served as an independent prognostic factor of adverse urothelial RFS in SU-treated patients with UC. Patients are advised to select surgical treatments for UC following the EAU guidelines.

Lynch syndrome screening in patients with young-onset extra-colorectal Lynch syndrome-associated cancers

BACKGROUND

Lynch syndrome (LS) is a hereditary cancer syndrome caused by pathogenic germline variants in mismatch repair (MMR) genes, which predisposes to various types of cancers showing deficient MMR (dMMR). Identification of LS probands is crucial to reduce cancer-related deaths in affected families. Although universal screening is recommended for colorectal and endometrial cancers, and age-restricted screening is proposed as an alternative, LS screening covering a broader spectrum of cancer types is needed. In the current study, we elucidated the rate of dMMR tumors and evaluated the outcome of LS screening in young-onset extra-colorectal LS-associated cancers.

METHODS

Immunohistochemistry for MMR proteins were retrospectively performed in a total of 309 tissue samples of endometrial, non-mucinous ovarian, gastric, urothelial, pancreatic, biliary tract, and adrenal cancers in patients < 50 years of age. Clinicopathological information and the results of genetic testing were obtained from medical charts.

RESULTS

There were 24 dMMR tumors (7.8%) including 18 endometrial, three ovarian, two urothelial, and one gastric cancer. Co-occurrence of colorectal cancer and family history of LS-associated cancers was significantly enriched in patients with dMMR tumors. Among the 16 patients with dMMR tumors who were informed of the immunohistochemistry results, five with endometrial and one with urothelial cancer were diagnosed as LS with positive pathogenic variants in MMR genes.

CONCLUSIONS

We report the outcome of immunohistochemistry for MMR proteins performed in multiple types of young-onset extra-colorectal LS-associated cancers. Our study demonstrates the feasibility of a comprehensive LS screening program incorporating young-onset patients with various types of extra-colorectal LS-associated cancers.

Clinical Significance of Tumor Location for Ureteroscopic Tumor Grading in Upper Tract Urothelial Carcinoma

Background: Although previous literature shows tumor location as a prognostic factor in upper tract urothelial carcinoma (UTUC), there remains uninvestigated regarding the impact of tumor location on grade concordance and discrepancies between ureteroscopic (URS) biopsy and final radical nephroureterectomy (RNU) pathology. Methods: In this international study, we retrospectively reviewed the records of 1,498 patients with UTUC who underwent diagnostic URS with concomitant biopsy followed by RNU between 2005 and 2020. Tumor location was divided into four sections: the calyceal-pelvic system, proximal ureter, middle ureter, and distal ureter. Patients with multifocal tumors were excluded from the study. We performed multiple comparison tests and logistic regression analyses. Results: Overall, 1,154 patients were included; 54.4% of those with low-grade URS biopsies were upgraded on RNU. In the multiple comparison tests, middle ureter tumors exhibited the highest probability of upgrading, meanwhile pelvicalyceal tumors exhibited the lowest probability of upgrading (73.7% vs 48.5%, p = 0.007). Downgrading was comparable across all tumor locations. On multivariate analyses, middle ureteral location was significantly associated with a low probability of grade concordance (odds ratio [OR] 0.59; 95% confidence interval [CI], 0.35-1.00; p = 0.049) and an increased risk of upgrading (OR 2.80; 95% CI, 1.20-6.52; p = 0.017). The discordance did not vary regardless of caliceal location, including the lower calyx. Conclusions: Middle ureteral tumors diagnosed to be low grade had a high probability to be undergraded. Our data can inform providers and their patients regarding the likelihood of undergrading according to tumor location, facilitating patient counseling and shared decision making regarding the choice of kidney sparing vs RNU.

Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma

OBJECTIVE

To assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI).

MATERIALS AND METHODS

Single center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications.

RESULTS

Overall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR.

CONCLUSIONS

Complications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

The impact of bladder cuff excision on outcomes after nephroureterectomy for upper tract urothelial carcinoma: An analysis of the ROBUUST 2.0 registry

OBJECTIVES

We sought to determine whether bladder cuff excision and its technique influence outcomes after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

METHODS AND MATERIALS

A multicenter, international, retrospective analysis using the ROBotic surgery for Upper tract Urothelial cancer Study (ROBUUST) 2.0 registry identified 1,718 patients undergoing RNU for UTUC between 2015 and 2023 at 17 centers across the United States, Europe, and Asia. Data was gathered on (1) whether bladder cuff excision was performed and (2) what technique was used, including formal excision or other techniques (pluck technique, stripping/intussusception technique) and outcomes. Multivariate and survival analyses were performed to compare the groups.

RESULTS

Most patients (90%, 1,540/1,718) underwent formal bladder cuff excision in accordance with EAU and AUA guidelines. Only 4% (68/1,718) underwent resection using other techniques, and 6% (110/1,718) did not have a bladder cuff excised. Median follow up for the cohort was 24 months (IQR 9-44). When comparing formal bladder cuff excision to other excision techniques, there were no differences in oncologic or survival outcomes including bladder recurrence-free survival (BRFS), recurrence-free survival (RFS), metastasis-free survival (MFS), overall survival (OS), or cancer-specific survival (CSS). However, excision of any kind conferred a decreased risk of bladder-specific recurrence compared to no excision. There was no difference in RFS, MFS, OS, or CSS when comparing bladder cuff excision, other techniques, and no excision.

CONCLUSIONS

Bladder cuff excision improves recurrence-free survival, particularly when considering bladder recurrence. This benefit is conferred regardless of technique, as long as the intramural ureter and ureteral orifice are excised. However, the benefit of bladder cuff excision on metastasis-free, overall, and cancer-specific survival is unclear.

Imaging of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) originates in the renal pelvis or ureters and typically affects elderly patients, with its incidence increasing over the past few decades. UTUC is a distinct clinical entity with more aggressive clinical behavior than that of lower tract urothelial carcinoma. Due to the significant challenge of acquiring an adequate tissue sample for biopsy, comprehensive risk stratification is required for treatment planning, including radical nephroureterectomy and kidney-sparing management. Imaging plays an important integrated role in risk assessment along with endoscopy and pathologic examination. Lifelong surveillance is required after treatment due to the high incidence of recurrent and metachronous tumors. Lynch syndrome is a frequently unrecognized genetic disorder associated with UTUC that warrants specific attention in patient management. UTUC may manifest with diverse imaging findings, including filling defects, wall thickening, and mass-forming lesions. CT urography is the preferred modality for diagnosis and staging or restaging of UTUC, with numerous technical variations. Efforts have been made to optimize image quality and radiation exposure. Due to its poor sensitivity for small lesions, use of MR urography is limited to special clinical scenarios (eg, when patients have contraindications to iodinated contrast agents). Fluorine 18 fluorodeoxyglucose PET helps to detect metastatic lesions. Image-guided biopsy may be considered for uncertain lesions. Radiologists need to be familiar with the imaging findings and their differential diagnoses. ©RSNA, 2024 Supplemental material is available for this article.

[New edition of the Paris classification 2022: What is new?]

As an internationally accepted diagnostic system, the Paris classification has achieved a global breakthrough in the standardization of diagnoses in urine cytology. Based on experience over the past few years since its first publication, the new edition of the Paris classification refines the diagnostic criteria and discusses diagnostic pitfalls. While the detection of high-grade urothelial carcinoma remains the main focus, other aspects of urine cytology, including cytology of the upper urinary tract and the associated challenges, have also been addressed. Low-grade urothelial neoplasia is no longer listed as a separate category but is now included in the category "negative for high-grade urothelial carcinoma" (NGHUC). Essentially, the Paris classification provides an important basis for estimating the risk of malignancy and further clinical management.

ACR Appropriateness Criteria® Pretreatment Staging of Urothelial Cancer: 2024 Update

Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of imaging for pretreatment staging of urothelial cancer are to evaluate for both local and distant spread of the cancer and assessing for synchronous sites of urothelial cancer in the upper tracts and bladder. For pretreatment staging of urothelial carcinoma, patients can be stratified into one of three groups: 1) nonmuscle invasive bladder cancer; 2) muscle invasive bladder cancer; and 3) upper urinary tract urothelial carcinoma. This document is a review of the current literature for urothelial cancer and resulting recommendations for pretreatment staging imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Upper tract urothelial carcinoma: epidemiology, presentation, and high-risk endemic populations

PURPOSE OF THE REVIEW

Upper tract urothelial carcinoma (UTUC) only accounts for 5-10% of all urothelial cancers but these patients present with high stage disease and 2 out of 3 patients have evidence of muscle-invasion at time of diagnosis. Furthermore, 10% of UTUC patients have associated Lynch syndrome and therefore diagnosis of UTUC should prompt timely evaluation and familial counseling. The purpose of this review is to outline the current evidence on the epidemiology, presentation, and high-risk endemic populations of UTUC through review of contemporary publications occurring over the preceding 18 months.

RECENT FINDINGS

Both the American Urological Association (AUA) and European Association of Urology (EAU) have published updated guidelines within the last 18 months for the management of UTUC. Of note, the updated guidelines give special consideration to identifying patients with risk factors for Lynch syndrome and recommend universal histologic testing for those with high probability of having Lynch syndrome cancers as well as referral for genetic counseling and germline testing.

SUMMARY

UTUC is an overall rare malignancy but tends to present with advanced stage and muscle-invasion. A proper understanding of the epidemiology, presentation, and high-risk endemic populations is necessary to develop preventive and interventional strategies.

Imaging for upper tract urothelial carcinoma: update of the evidence and a glimpse into the future

PURPOSE OF REVIEW

Upper tract urothelial carcinoma (UTUC) is a rare malignancy posing significant diagnostic and management challenges. This review provides an overview of the evidence supporting various imaging modalities and offers insights into future innovations in UTUC imaging.

RECENT FINDINGS

With the growing use of advancements in computed tomography (CT) technologies for both staging and follow-up of UTUC patients, continuous innovations aim to enhance performance and minimize the risk of excessive exposure to ionizing radiation and iodinated contrast medium. In patients unable to undergo CT, magnetic resonance imaging serves as an alternative imaging modality, though its sensitivity is lower than CT. Positron emission tomography, particularly with innovative radiotracers and theranostics, has the potential to significantly advance precision medicine in UTUC. Endoscopic imaging techniques including advanced modalities seem to be promising in improved visualization and diagnostic accuracy, however, evidence remains scarce. Radiomics and radiogenomics present emerging tools for noninvasive tumor characterization and prognosis.

SUMMARY

The landscape of imaging for UTUC is rapidly evolving, with significant advancements across various modalities promising improved diagnostic accuracy, patient outcomes, and safety.

Precise grading of non-muscle invasive bladder cancer with multi-scale pyramidal CNN

The grading of non-muscle invasive bladder cancer (NMIBC) continues to face challenges due to subjective interpretations, which affect the assessment of its severity. To address this challenge, we are developing an innovative artificial intelligence (AI) system aimed at objectively grading NMIBC. This system uses a novel convolutional neural network (CNN) architecture called the multi-scale pyramidal pretrained CNN to analyze both local and global pathology markers extracted from digital pathology images. The proposed CNN structure takes as input three levels of patches, ranging from small patches (e.g., 128 × 128 ) to the largest size patches ( 512 × 512 ). These levels are then fused by random forest (RF) to estimate the severity grade of NMIBC. The optimal patch sizes and other model hyperparameters are determined using a grid search algorithm. For each patch size, the proposed system has been trained on 32K patches (comprising 16K low-grade and 16K high-grade samples) and subsequently tested on 8K patches (consisting of 4K low-grade and 4K high-grade samples), all annotated by two pathologists. Incorporating light and efficient processing, defining new benchmarks in the application of AI to histopathology, the ShuffleNet-based AI system achieved notable metrics on the testing data, including 94.25% ± 0.70% accuracy, 94.47% ± 0.93% sensitivity, 94.03% ± 0.95% specificity, and a 94.29% ± 0.70% F1-score. These results highlight its superior performance over traditional models like ResNet-18. The proposed system's robustness in accurately grading pathology demonstrates its potential as an advanced AI tool for diagnosing human diseases in the domain of digital pathology.

Prognostic evaluation of segmental ureterectomy combined with chemotherapy in high-grade non-metastatic ureteral cancer: a study based on the SEER database

This study evaluates the survival outcomes of segmental ureterectomy (SU) combined with chemotherapy in patients with high-grade non-metastatic ureteral cancer (UC) using data from the SEER database. A total of 1757 patients with Grade III-IV non-metastatic UC were analyzed. Overall survival (OS) was assessed through Kaplan-Meier analysis, and independent prognostic factors were identified via Cox regression. A Nomogram model was developed and evaluated using the concordance index, area under the time-dependent ROC curve, calibration curves, and decision curve analysis. The 1-, 3-, and 5-year OS rates were 82.8%, 55.6%, and 42.8%, respectively. Age, treatment protocol, T stage, and N stage were significant prognostic factors. Both SU + chemotherapy and radical nephroureterectomy (RNU) + chemotherapy demonstrated comparable survival outcomes, outperforming surgery alone, particularly in patients aged 70 and older. The Nomogram demonstrated high predictive accuracy and clinical utility. These findings suggest that SU + chemotherapy offers survival benefits similar to RNU + chemotherapy, making it a viable option, especially for elderly patients or those with impaired renal function.