Endoscopic Management of Upper Tract Transitional Cell Carcinoma in Patients with Normal Contralateral Kidneys

An evaluation of mitomycin-containing reverse thermal gel for the treatment of low-grade upper tract urothelial carcinoma

INTRODUCTION

Endoscopic management of upper tract urothelial carcinoma (UTUC) is increasingly relevant with greater detection of low-grade disease and guidelines recommending kidney preservation for low-risk disease. Historically, laser or thermal ablation has served as the primary tool for endoscopic management of UTUC, however, chemoablation is rapidly being developed to serve as a primary or adjuvant treatment option, which warrants review.

AREAS COVERED

The current literature was reviewed to compare the outcomes and clinical utility of endoscopic treatment modalities for low-grade UTUC, with a focus on mitomycin-containing reverse thermal gel (UGN-101).

EXPERT OPINION

The overall outcomes of mitomycin-containing gel therapy are promising, but adverse effects such as ureteral stricture call for careful consideration when using this treatment. We believe it is reasonable to consider use of mitomycin-containing gel as an adjuvant chemotherapy with endoscopic laser resection of low-grade upper tract urothelial carcinoma.

Longer is Better for Endoscopic Follow-up of Upper Tract Urothelial Carcinoma After Ureteroscopic Treatment: An Evaluation Spanning 10 Years of Data

BACKGROUND

Tumour recurrences are frequent among patients with upper tract urothelial carcinoma (UTUC) treated with ureteroscopy (URS). Therefore, guidelines recommend a strict follow-up regimen, but there is little evidence on how to do this.

OBJECTIVE

To analyse outcomes during our follow-up regimen and the impact on treatment in terms of ipsilateral UTUC recurrence, treatment conversion, and tumour upgrading, and to evaluate potential prognostic factors, including second-look URS outcomes. A secondary objective was to evaluate survival outcomes.

DESIGN, SETTING, AND PARTICIPANTS

The single-centre cohort included all adult patients with nonmetastatic UTUC treated with URS from January 2010 to December 2020. Follow-up involved endoscopy at 3-mo intervals in the first year, then at 6-mo intervals up to year 3, and yearly thereafter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Descriptive analyses were performed for the follow-up outcomes. The Andersen-Gill model for recurrent event analysis was used to analyse tumour recurrences, and multivariable Cox regression to analyse for predictors for treatment conversion in low-grade tumours.

RESULTS AND LIMITATIONS

We analysed 71 patients with median follow-up of 49.5 mo. The overall 2-yr recurrence-free survival (RFS) rate was 22%. In low-grade disease, the 1-yr RFS rate was 50% and the 2-yr RFS rate was 29%. Treatment was converted to radical nephroureterectomy for 23 patients, at a median time to conversion of 9.9 mo. Upgrading was seen in 13 patients, at a median time to upgrading of 21.9 mo. No factors were prognostic for either tumour recurrence or treatment conversion. The 5-yr OS, CSS, and MFS rates were 82%, 86%, and 84%, respectively.

CONCLUSIONS

Our data show that it is rational to extend endoscopic follow-up for UTUC treated with URS, as clinically relevant events (treatment conversion and tumour upgrading) occur beyond the current 6-mo guideline recommendation. Second-look URS outcomes were not prognostic for tumour recurrence or treatment conversion during follow-up.

PATIENT SUMMARY

Our study results show that for patients with cancer of the upper urinary tract treated with kidney-sparing surgery through a small telescope called a ureteroscope (URS), most of the clinically relevant events (treatment conversion and tumour upgrading) occur outside the current recommended follow-up of 6 months. Therefore, URS follow-up should be extended for these patients.

Complete Pathologic Response With Pembrolizumab and Enfortumab Vedotin in Urothelial Carcinoma of the Upper Urinary Tract

Urothelial carcinoma of the upper urinary tract (UTUC) presents a significant clinical challenge, often requiring aggressive surgical intervention for optimal management. We present a case of an 84-year-old woman with recurrent high-grade papillary UTUC of the left renal pelvis, refractory to prior endourologic interventions, who underwent neoadjuvant treatment with pembrolizumab and enfortumab vedotin (Pembro/EV) due to contraindications to cisplatin therapy. Following a favorable response to neoadjuvant therapy, the patient underwent laparoscopic left radical nephroureterectomy, achieving a pathologic complete response. We discuss the utility of Pembro/EV in the perioperative management of patients with UTUC, particularly in those ineligible for cisplatin-based therapy. In addition, we highlight the potential role of somatic mutation testing and the integration of novel therapeutic agents such as olaparib in personalized treatment strategies for UTUC. This case underscores the importance of exploring innovative treatment approaches and optimizing patient selection for kidney preservation strategies in the management of UTUC. Further research and clinical trials are warranted to elucidate the full therapeutic potential of Pembro/EV and other emerging therapies in this setting.

Oncologic and Safety Outcomes for Retrograde and Antegrade Endoscopic Surgeries for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis

The aim of this study was to identify and summarize available data on oncologic and safety outcomes for retrograde versus antegrade endoscopic surgery in patients with upper tract urothelial carcinoma (UTUC). We systematically searched studies reporting on endoscopic surgery in patients with UTUC. The primary outcome of interest was oncologic control, including bladder and upper urinary tract recurrences. The secondary outcomes were any-grade and major complications. Twenty studies comprising 1091 patients were included in our analysis. The pooled bladder recurrence rate was 35% (95% confidence interval [CI] 28.0-42.3%; I² = 48%) after retrograde endoscopic surgery and 17.7% (95% CI 6.5-32.1%; I² = 29%) after antegrade endoscopic surgery. The pooled upper urinary tract recurrence rate was 56.4% (95% CI 41.2-70.9; I² = 93%) after retrograde endoscopic surgery and 36.2% (95% CI 25.5-47.6%; I² = 57%) after antegrade endoscopic surgery. The pooled complication rate was 12.5% (95% CI 0.8-32.8%; I² = 94%) for any-grade complications and 6.6% (95% CI 0.1-19.1%; I² = 89%) for major complications in the retrograde endoscopic cohort. In summary, our analyses suggest promising oncologic benefits of antegrade kidney-sparing surgery in terms of bladder and upper urinary tract recurrence rates in UTUC. Retrograde endoscopic surgery is a safe procedure with a minimal risk of complications and acceptable oncologic outcomes. Research should address the hypothesis that endoscopic antegrade surgery can be a safe and effective alternative for well-selected patients. PATIENT SUMMARY: One of the surgical options for treatment of cancer of the upper urinary tract is removal of the tumor through a small telescope called an endoscope. The endoscope can be inserted via the urethra (called a retrograde approach) or through a small incision in the skin (antegrade approach). Our review shows that the antegrade approach seems to provide acceptable cancer control rates. Further research could help to identify the role for endoscope surgery in cancer of the upper urinary tract.

Role of Ureteroscopy in Treatment of Upper Tract Urothelial Carcinoma

PURPOSE OF REVIEW

Upper tract urothelial carcinoma (UTUC) is uncommon accounting for less than 10% of all urothelial tumours. Ureteroscopic management (URS) is the first line treatment for low-risk disease and has been increasingly utilised due to technological advances and increasing surgical experience. This review looks at patient outcomes relating to URS, emerging technologies and the role of adjuvant intracavitary therapy in the management of UTUC.

RECENT FINDINGS

URS has firmly established itself in the management algorithm for UTUC, and a good body of evidence supports its use for low-risk disease, wherein oncological outcomes are comparable to traditional nephroureterectomy (RNU). Larger tumours can now be managed using URS with a lower morbidity than radical surgery, though with higher associated local recurrence rate and risk of progression to RNU, and as a result, patient selection and close surveillance remains key. There is limited evidence for adjuvant intracavitary therapy (Mitomycin C or BCG) in UTUC although the development of novel polymers and biodegradable stents may improve drug delivery to the upper urinary tract. URS has a clearly defined role in low-risk UTUC, and its use in larger tumours appears to be appropriate in a selected cohort of patients. The efficacy of adjuvant intracavitary therapy is as of yet undetermined, though developments in delivery techniques are promising. Likewise further developments of laser technology are anticipated to further expand the role of URS.

Stereotactic Body Radiotherapy for Palliation of Hematuria Arising From Urothelial Carcinoma of the Kidney in Unfavorable Surgical Candidates

INTRODUCTION

Hematuria can be a distressing and debilitating complication of urothelial carcinoma (UC) of the kidney for patients who are not candidates for surgery or ureteroscopic ablation. We retrospectively assessed the efficacy, tolerability, and safety of stereotactic body radiotherapy (SBRT) for controlling gross hematuria in this patient population.

MATERIALS AND METHODS

Institutional Review Board (IRB)-approved review of the records, laboratory values, pathology, and imaging of 8 consecutive patients treated with SBRT over a 5-year period for uncontrolled gross hematuria caused by UC of the renal pelvis or calyces.

RESULTS

Therapy was delivered in 3 to 5 treatments over 1 to weeks. Individual treatments lasted an average of 17.2 minutes. No patient experienced treatment-related pain, vomiting, or diarrhea. All enjoyed cessation of bleeding within a week of completing therapy. Hematuria recurred in 2 patients in 4 and 22 months. Of the patients who have not re-bled, 3 expired of metastatic disease or co-morbidities, and 3 remain alive up to 6 years posttreatment. Of patients who have survived longer than a year, creatinine has changed by -0.05 to +0.35, and estimated glomerular filtration rate has fallen by an average of 22%. No patient has required dialysis.

CONCLUSIONS

SBRT appears to be an effective and well-tolerated means of palliating gross hematuria secondary to UC of the renal pelvis or calyces in patients who are unfavorable candidates for nephrectomy or ureteroscopic ablation. Treatment was associated with a moderate decline in renal function.

Long-term ureteroscopic management of upper tract urothelial carcinoma: 28-year single-centre experience

BACKGROUND

Long-term survival outcomes of patients who undergo endoscopic management of non-invasive upper tract urothelial carcinoma remain uncertain. The longest mean follow-up period in previous studies was 6.1 years. This study reports the long-term outcomes of patients with upper tract urothelial carcinoma who underwent ureteroscopic ablation at a single institution over a 28-year period.

METHODS

We identified all patients who underwent ureteroscopic management of upper tract urothelial carcinoma as their primary treatment at our institution between January 1991 and April 2011. Survival outcomes, including overall survival, cancer-specific survival, upper-tract recurrence-free survival and renal unit survival, were estimated using Kaplan-Meier methodology.

RESULTS

A total of 15 patients underwent endoscopic management, with a mean age at diagnosis of 66 years. All patients underwent ureteroscopy, and biopsy-confirmed pathology was obtained. Median (range; mean) follow-up was 11.7 (2.3-20.9, 11.9) years. Upper tract recurrence occurred in 87% (n = 13) of patients. Twenty percent (n = 3) of patients proceeded to nephroureterectomy. The estimated cancer-specific survival rate was 93% at 5, 10, 15 and 20 years. Estimated overall survival rates were 86, 80, 54 and 20% at 5, 10, 15 and 20 years. Only one patient experienced cancer-specific mortality. The estimated mean and median overall survival times were 14.5 and 16.6 years, respectively. The estimated mean cancer-specific survival time was not reached.

CONCLUSIONS

Although upper tract recurrence is common, endoscopic management of non-invasive upper tract urothelial carcinoma provides a 90% cancer-specific survival rate at 20 years in selected patients.

Outcomes of endoscopic management of upper tract urothelial carcinoma

While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.

Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma

Though radical nephroureterectomy remains the gold standard treatment for high grade or invasive disease in upper tract urothelial cancer (UTUC), kidney-sparing surgery has become preferred for low risk disease, in order to minimize morbidity and preserve renal function. Many methods exist for endoscopic management, whether via an antegrade percutaneous or retrograde ureteroscopic approach, including electroresection, laser ablation, and fulguration. There has been an increase in use of adjuvant intracavitary therapy, predominantly using mitomycin and bacillus Calmette-Guerin (BCG), to reduce recurrence after primary endoscopic management for noninvasive tumors, although efficacy remains questionable. Intraluminal BCG has additionally been used for primary treatment of CIS in the upper tract, with around 50% success. Newer investigations include use of narrow band imaging or photodynamic diagnosis with ureteroscopy to improve visualization during diagnosis and treatment. Genomic characterization may improve selection for kidney-sparing surgery as well as identify actionable mutations for systemic therapy. The evolution in adjuvant management has seen strategies to increase the dwell time and the urothelial contact of intraluminal agents. Lastly, chemoablation using a hydrogel for sustained effect of mitomycin is under investigation with promising early results. Continued expansion of the armamentarium available and better identification and characterization of tumors ideal for organ-sparing treatment will further improve kidney preservation in UTUC.

[Instillation therapies for urothelial carcinoma of the upper urinary tract]

Traditionally, urothelial carcinoma of the upper urinary tract was a clear indication for radical nephroureterectomy with bladder cuff excision. It has been shown that in well-selected patients and depending on tumor stage, a kidney-sparing approach can be pursued with good oncological outcome and equivalent to the radical approach. The prevention of local and bladder recurrences is an important factor. Instillation therapies with bacillus Calmette-Guérin and/or mitomycin C have been successfully used to this end. Due to the low incidence of upper tract urothelial cancer and due to the usually retrospective nature of existing literature, however, data is limited. In this article, we provide a review of the indication, technical execution and results of instillation therapies of the upper urinary tract.

Recent advances in upper tract urothelial carcinomas: From bench to clinics

Urothelial carcinoma in the upper tract is rare and often discussed separately. Many established risk factors were identified for the disease, including genetic and external risk factors. Radiographic survey, endoscopic examination and urine cytology remained the most important diagnostic modalities. In localized upper tract urothelial carcinomas, radical nephroureterectomy with bladder cuff excision are the gold standard for large, high-grade and suspected invasive tumors of the renal pelvis and proximal ureter, whereas kidney-sparing surgeries should be considered in patients with low-risk disease. Advances in technology have given endoscopic surgery an important role, not only in diagnosis, but also in treatment. Although platinum-based combination chemotherapy is efficacious in advanced or metastatic disease, current established chemotherapy regimens are toxic and lack a sustained response. Immune checkpoint inhibitors have led to a new era of treatment for advanced or metastatic urothelial carcinomas. The remarkable results achieved thus far show that immunotherapy will likely be the future treatment paradigm. The combination of immune checkpoint inhibitors and other agents is another inspiring avenue to explore that could benefit even more patients. With respect to the high incidence rate and different clinical appearance of upper tract urothelial carcinomas in Taiwan, a possible correlation exists between exposure to certain external risk factors, such as arsenic in drinking water and aristolochic acid in Chinese herbal medicine. As more gene sequencing differences between upper tract urothelial carcinomas and various disease causes are detailed, this has warranted the era of individualized screening and treatment for the disease.

Advances in the management of upper tract urothelial carcinoma: improved endoscopic management through better diagnostics

As a rare disease, the management of upper tract urothelial carcinoma (UTUC) continues to evolve. While radical nephroureterectomy remains the gold standard, there is a growing desire to pursue nephron-sparing approaches through endoscopic management, particularly for low-risk disease or in the setting of imperative indications. A particular challenge for those undertaking endoscopic management is appropriate grading and staging of tumors, and thereby appropriate patient selection. In this review we will cover the current state of diagnostics for UTUC as well as highlight the challenges in accurate diagnosis. Additionally, we will focus on emerging technologies to aid in optimizing diagnostic accuracy in UTUC. This will include discussion of narrow band imaging, photodynamic diagnosis, optical coherence tomography, and confocal laser endomicroscopy.

Endoscopic Approaches to Upper Tract Urothelial Carcinoma

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

Thulium Laser Treatment of Upper Urinary Tract Carcinoma: A Multi-Institutional Analysis of Surgical and Oncological Outcomes

INTRODUCTION

To evaluate the efficacy and safety of ureteroscopic thulium laser (TL) treatment of upper urinary tract carcinoma (UTUC).

MATERIALS AND METHODS

Forty-two consecutive patients underwent conservative TL treatment for UTUC at two referral institutions. All patients underwent preliminary biopsy and then laser vaporization. A 272 μm and 365 μm laser fibers were used with a flexible and semirigid scope, respectively. Ablation was carried out with a 10 to 20 W power.

RESULTS

Mean age at surgery was 68 years (SD 10.7). Mean tumor size was 14.3 mm (range 2-30 mm). Preliminary biopsy revealed the presence of low-grade disease in 29 (69.1%) patients, high-grade disease in 4 (9.5%) and 1 carcinoma in situ 1 (2.4%), whereas it was not conclusive in 8 (19%) cases. Final stage was pTa and pTis in 41 (97.6%) and 1 (2.4%) patients, respectively. Thirty eight percent (16) experienced Clavien-Dindo grade I complication, 47.6% (20) grade II, and 2.4% (1) grade III. Five (12%) patients underwent a second-look procedure due to residual disease. Eight (19%) patients experienced clinical recurrence. The median estimated recurrence-free survival was 44 months (SE 3.68). Four patients (9.5%) underwent a nephroureterectomy. Final pathological stage was pTis, pT3 high grade, pTa low grade, and pT0. Median follow-up was 26.3 months (range 2-54 months), and no progression or upstaging of disease occurred.

CONCLUSIONS

TL management of UTUC is a safe and efficacious conservative treatment. Our experience shows optimal vaporization and hemostatic control in the absence of major complications.

Which Patients with Upper Tract Urothelial Carcinoma Can be Safely Treated with Flexible Ureteroscopy with Holmium:YAG Laser Photoablation? Long-Term Results from a High Volume Institution

PURPOSE

We tested the effects of tumor size, distribution and grade on progression-free survival in patients with upper tract urothelial carcinoma treated with flexible ureteroscopy with Ho:YAG laser photoablation.

MATERIALS AND METHODS

Included in analysis were data on 92 consecutive patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation from 2003 to 2015 at a single tertiary care referral center. Stringent followup was offered according to EAU (European Association of Urology) guidelines. Progression during followup was defined by tumor upgrading, distant metastases and/or a relapsing tumor that could not be completely removed with a conservative approach. Kaplan-Meier curves were used to assess the rate of disease progression according to tumor size (1 or less cm vs greater than 1 cm), tumor distribution (unifocal vs multifocal) and tumor grade (low vs high). Cox regression analysis was done to test the impact of clinical and pathological characteristics on the rate of progression-free survival.

RESULTS

At a median followup of 52 months (IQR 27.8-76.4) the progression-free survival rate was 68% vs 72% in patients with a tumor size of 1 or less vs greater than 1 cm (p = 0.9), 72% vs 69% in patients with unifocal vs multifocal lesions (p = 0.6) and 75% vs 52% in patients with a low vs a high grade tumor (p = 0.03). On multivariable Cox regression analysis tumor grade at first treatment was the only independent predictor of disease progression (HR 5.16, 95% CI 1.19-22.26, p = 0.03).

CONCLUSIONS

High tumor grade independently decreased progression-free survival in patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation. Tumor size greater than 1 cm and multifocality did not increase the risk of disease progression in patients treated conservatively with Ho:YAG laser photoablation.

Induction and Maintenance Adjuvant Mitomycin C Topical Therapy for Upper Tract Urothelial Carcinoma: Tolerability and Intermediate Term Outcomes

PURPOSE

Endoscopic management of upper tract urothelial carcinoma (UTUC) is associated with higher recurrences, which could be reduced by application of topical therapy. Adjuvant induction Bacillus Calmette-Guerin has shown inferior outcomes for UTUC compared to bladder cancer, and maintenance regimens for UTUC are unexplored. We report on the efficacy, safety, and tolerability of Mitomycin C (MMC) induction and maintenance adjuvant topical therapy for UTUC.

MATERIALS AND METHODS

Patients with UTUC who received adjuvant topical therapy after complete endoscopic control of Ta/T1 tumors were retrospectively reviewed. Patients were treated using percutaneous nephrostomy tube (NT) or cystoscopically placed weekly ureteral catheters, per patient preference, and all patients were offered induction and maintenance. Standardized follow-up of every 3 months in the first year, then at a minimum every 6 months, with ureteroscopy and at least annual CT, was performed. Primary outcomes were recurrence-free, progression-free, nephroureterectomy-free rate and cancer-specific and overall survival. Secondary outcomes were safety and treatment tolerability.

RESULTS

Twenty-seven patients with 28 renal units received adjuvant topical therapy from January 2008 to March 2015. Median follow-up was 19 months (range 7-92). Three year recurrence-free, progression-free, and nephroureterectomy-free survival rates were 60% [confidence interval (95% CI): 42, 86%], 80% [95% CI: 64, 100%], and 76% [95% CI: 60, 97%]. Cancer-specific mortality rate was 0%, and 3-year overall survival was 92.9%. Nine patients experienced adverse outcomes, all related to interventions and none related to systemic toxicity.

CONCLUSIONS

Induction and maintenance adjuvant topical MMC for endoscopically resected UTUC is feasible, well tolerated and shows promising intermediate term data on recurrence, progression, and nephroureterectomy-free survival.

Endoscopic Treatment of Upper Tract Urothelial Carcinoma

PURPOSE OF REVIEW

This study aims to make the reader be aware of recent trends regarding the endoscopic management of upper tract urothelial carcinoma (UTUC) via review of the urologic literature over the past 5 years. Given the rare incidence of this disease, and the lack of level 1 evidence, systematic reviews and meta-analyses were also evaluated. Studies of importance are also considered and outlined in the annotated reference section.

RECENT FINDINGS

The PubMed database was queried using the following medical subject headings (MeSH terms): "carcinoma, transitional cell," "ureter," "ureteral neoplasms," "kidney pelvis," "endoscopy," "laser therapy," "ureteroscopy," "urologic surgical procedures," and "ureteroscopes." MeSH terms were linked together in varying combinations and limited to human studies in English. Given the relatively rare nature of upper tract urothelial carcinoma (UTUC), level 1 evidence regarding the efficacy of endoscopic treatment does not exist, even after 30+ years of experience. Rather, the literature available mostly is in the form of single institutional retrospective series consisting of relatively small numbers of patients with short to intermediate follow-up. Only within the last 3 years have published series with larger numbers of patients and mean follow-up over 5 years been made available. Even with these more robust experiences, comparisons among series are difficult given variable treatment and follow-up approaches. Most endoscopically managed UTUC will locally recur, especially with longer follow-up. Renal preservation rate is high, however, approaching 80% with follow-up well over 3 years. Patients with high-grade disease often fare poorly regardless of treatment modality. As such, endoscopic management for high-grade urothelial carcinoma should only be used in exceptional circumstances (i.e., in those patients medically unfit for NU or those with solitary kidneys wishing to avoid the morbidity of dialysis). No level 1 evidence exists for the routine use of intraluminal adjuvant therapy for UTUC (i.e., BCG and Mitomycin C) and multiple retrospective observational series claim there is no overt benefit. The recent formation of multiple international groups with interest in UTUC may eventually lead to the production of level 1 studies regarding optimal treatment; however, uniformity in treatment approach will likely still offer challenges.

Why are upper tract urothelial carcinoma two different diseases?

In the last few years growing evidence highlighted the differences between upper tract urothelial carcinoma (UTUC) and urothelial bladder carcinoma (UBC) which cannot be explained solely by their different anatomical location. The aim of this review was to summarize current progress in UTUC research and to underline the differences and similarities between UTUC and UBC by focusing on epidemiology, etiology, staging and risk factors as well as on surgical and medical management. UBC and UTUC sharing common risk factors such as smoking and aromatic amines, while aristolochic acid exposure or familiar Lynch syndrome are rather specific for UTUC. The grading of UBC and UTUC are identical, but inherent from their different anatomical locations, there are some differences between their stage classifications. As an example, in contrast to UBC where a clear recommendation for pT3 subclassification exists, in UTUC current research aims to define an adequate subclassification for pelvic pT3 cases aiming to provide a better risk stratification. The primary treatment for both UBC and UTUC is surgery. Similarly to UBC, UTUC patients at high risk of disease progression are treated by radical surgery. However, because of the inaccurate preoperative or transurethral staging of UTUC, many radical nephroureterectomies are performed unnecessarily. Preoperative prediction of pathological stage or patients' prognosis may reduce this overtreatment by selecting patients for nephron-sparing surgery. To this end, predictive models combining histological and molecular features together with imaging data may be used. The antegrade or retrograde instillation of BCG or mitomycin C, as topical agents is feasible after conservative treatment of UTUC or for the treatment of CIS. However, the prognostic significance of lymph node positivity in UTUC seems to be similar to that of UBC, the therapeutic benefit of lymph node dissection (LND) in UTUC has not been firmly established yet. In addition, the number of lymph nodes to be removed and the sequence of lymphadenectomy also remain to be defined. Systemic neoadjuvant and adjuvant chemotherapies appear to have beneficial effect on UTUC survival, however, this has to be confirmed by large prospective studies. Due to the intensive research of the last few years, our knowledge on UTUC has been largely improved, but many questions remained to be answered. Further research on the molecular background of UTUC holds the potential to identify prognostic or predictive markers which, together with imaging and histologic data, may help to overcome the inaccuracy of ureteroscopic endoscopy and may therefore help to improve therapeutic decision-making. Further, prospective studies should confirm the benefit of LND and adjuvant chemotherapy. Considering the low incidence of UTUC, conduction of such studies is difficult and may only be performed in a multicenter setting.

Impact of Ureteroscopy Before Nephroureterectomy for Upper Tract Urothelial Carcinoma on Oncologic Outcomes

OBJECTIVE

To compare the oncologic outcomes of patients with upper tract urothelial carcinoma undergoing nephroureterectomy (NU) with and without prior ureteroscopy (URS).

METHODS

We reviewed records of all patients with no prior history of bladder cancer who underwent NU at our institution (n = 201). We compared patients who underwent URS before NU with patients who proceeded directly to NU based on imaging alone. After excluding patients undergoing URS with therapeutic intent, we used multivariable Cox proportional hazards models, adjusting for tumor characteristics with cancer-specific survival (CSS), intravesical recurrence-free survival, metastasis-free survival (MFS), and overall survival (OS) as end points. This study received institutional review board approval.

RESULTS

A total of 144 (72%) patients underwent URS before NU, and 57 (28%) patients proceeded directly to NU. The median follow-up time for survivors was 5.4 years from diagnosis. The performance of diagnostic URS before NU was significantly associated with IR (hazard ratio 2.58; 95% CI 1.47, 4.54; P = .001), although it was not associated with CSS, MFS, or OS. The adjusted intravesical recurrence-free survival probability 3 years after diagnosis is 71% and 42% for patients who did not and did receive URS before NU, respectively (adjusted risk difference 30%; 95% CI 13%, 47%).

CONCLUSION

We did not find evidence that URS adversely impacts disease progression and survival in patients with upper tract urothelial carcinoma. Although patients are at higher risk for IR after NU when they have undergone prior diagnostic URS, their CSS, MFS, and OS are not significantly affected.

Evaluation of endourological tools to improve the diagnosis and therapy of ureteral tumors – from model development to clinical application

Adequate diagnosis of upper urinary tract (UUT) tumors is essential for successful local treatment. Organsparing approaches are technically difficult and require consistent further development. Appropriate models for investigating new diagnostic and therapeutic methods are not yet available. This study demonstrates the incorporation of a fresh sample model into five different test levels (I-V) for improving the diagnosis and therapy of ureteral tumors. In these test levels, new diagnostic and ablation techniques are evaluated for feasibility, application safety, efficacy and accuracy. An assessment of their suitability for broad preclinical and clinical application also took economic aspects into account.

Oncologic results of nephron sparing endoscopic approach for upper tract low grade transitional cell carcinoma in comparison to nephroureterectomy - a case control study

Background

There is paucity of data as to the results of the endoscopic approach in comparison to the golden standard of nephro-ureterectomy in elective, low grade TCC, patients. Our purpose is to report our results of a nephron sparing approach compared to nephro-ureterectomy in those patients.

Methods

From a retrospective data base we identified 25 patients and 23 patients who underwent a nephron sparing ureterosocpic resection and nephro-reterectomy for low grade UT-TCC, respectively. The endoscopic technique included endoscopic tumor biopsy followed by primary resection and/or fulguration. The nephron sparing group was followed by bi-annual ureteroscopy and upper tract imaging, timely cystoscopy and urine cytology collection. Data for overall and disease related mortality, bladder and ureteral TCC recurrence and renal function are reported in both groups.

Results

Median follow - up time was 26 months. 11 (44%) patients developed bladder recurrence at a median period of 9 months after initial ureteroscopy, compared to 9 (39%) in the NUx group (P < 0.05). Recurrent ureteral low grade TCC was observed in 9 patients (median: 9 months). All were treated endoscopicaly successfully. Renal function remained stable in the nephron sparing group. No disease related mortality was recorded in the nephron-sparing group while one patient died of his disease following NUx.

Conclusions

Disease related mortality following a nephron sparing endoscopic approach or nephroureterectomy for low grade upper tract TCC is excellent. However, the nephron sparing approach is associated with a relatively high rate of ureteral and bladder recurrence. Therefore, a stringent follow-up protocol is required.

The significance of functional renal obstruction in predicting pathologic stage of upper tract urothelial carcinoma

BACKGROUND AND PURPOSE

Assessing the severity of upper tract urothelial carcinoma (UTUC) has been difficult because of inadequate biopsy specimens. Additional predictive parameters of disease stage would be useful when deciding a treatment plan; it has been suggested that preoperative hydronephrosis can be a surrogate. We examined the relationship between preoperative ipsilateral renal obstruction identified by imaging with final pathologic stage after nephroureterectomy (NU) for UTUC. We then analyzed those patients with ipsilateral renal obstruction and examined if tumor location is associated with an advanced pathologic stage.

METHODS

Patients who underwent NU for UTUC between the years 2001 to 2013 were analyzed and relevant staging studies and pathology were reviewed. Criteria for ipsilateral renal obstruction were defined by the presence of a delayed nephrogram on CT scan, renal cortical atrophy with associated hydronephrosis on cross-sectional imaging, and/or >10% split function discrepancy on nuclear renal scintigraphy with associated hydronephrosis.

RESULTS

Eighty-two patients met inclusion criteria; 26/82 (31.7%) had locally advanced disease (pT3/T4), while 56/82 (63.4%) had organ-confined (≤pT2) disease. Of the patients with pT3/T4 disease, 10/26 (38.5%) demonstrated radiographic evidence of functional obstruction of the ipsilateral renal unit; similarly, in patients with ≤pT2 disease, 21/56 (37.5%) demonstrated ipsilateral renal obstruction (P=0.93). Of the patients with ipsilateral renal obstruction, in those patients with pT3/T4 disease, 7/10 (70.0%) had ureteral tumor involvement while 9/21 (42.9%) patients with ≤pT2 disease had tumor in the ureter (P=0.25).

CONCLUSIONS

This study suggests that renal obstruction by radiographic analysis does not always predict advanced stage. In addition, there is a trend toward advanced stage when a patient has radiographic evidence of ipsilateral renal dysfunction and a ureteral tumor.

Ureteroscopic laser treatment of upper urinary tract urothelial cell carcinomas: can a tumour free status be achieved?

Introduction. In cases of anatomic or functional single kidney with urothelial tumours of the upper urinary tract, the endoscopic laser ablation has proven efficacious. Based on the knowledge that low-grade, low-stage upper tract transitional cell carcinomas rarely progress to invasive lesions, indications for endoscopic laser ablation have expanded to include patients with bilateral functioning kidneys and low-grade tumours. The question that remains to be answered is whether endoscopic laser ablation has the ability to completely eradicate upper urinary tract tumours. Methods. We performed in 25 patients in a period of 11 years 288 ureteroscopies and, if needed, laser ablation of upper urinary tract tumours in imperative indication. Results. In 32% of the patients the cancer remained even after several laser sessions. 64% of patients were tumour free after one or more laser sessions but remained clear only for the next 3 months. Only 1 patient was tumour free for a period of 68 months after 1 session of laser treatment. The procedure had low complication rates. Conclusion. The laser technology and the introduction of small diameter semirigid and flexible ureteroscopes made ablation of upper urinary tract tumours possible and safe. Nevertheless a complete resection of the carcinomas is rarely possible.

Endoscopic spray cryotherapy for genitourinary malignancies: safety and efficacy in a porcine model

OBJECTIVE

To examine the effects and safety of using endoscopic spray cryotherapy (ESC) on bladder, ureteral, and renal pelvis urothelium in a live porcine model.

SUBJECTS AND METHODS

ESC treatments were systematically applied to urothelial sites in the bladder, ureter, and renal pelvis of eight female Yorkshire swine in a prospective trial. Freeze-thaw cycles ranged from 5 to 60 s/cycle for one to six cycles using a 7 French cryotherapy catheter. Tissue was evaluated histologically for treatment-related effects. Acute physiologic effects were evaluated with pulse oximetry, Doppler sonography, and postmortem findings.

RESULTS

In bladder, treatment depth was inconsistent regardless of dose, demonstrating urothelial necrosis in one, muscularis propria depth necrosis in two, and full thickness necrosis in all remaining samples. In ureter, full thickness necrosis was seen in all samples, even with the shortest spray duration (5 s/cycle for six cycles or 30 s/cycle for one cycle). Treatment to the renal pelvis was complicated by adiabatic gas expansion of liquid nitrogen to its gaseous state, resulting in high intraluminal pressures requiring venting to avoid organ perforation, even at the lowest treatment settings. At a planned dose of 5 s/cycle for six cycles of the first renal pelvis animal, treatment was interrupted by sudden and unrecoverable cardiopulmonary failure after three cycles. Repeated studies replicated this event. Ultrasound and immediate necropsy confirmed the creation of a large gaseous embolism and reproducible cardiopulmonary effects.

CONCLUSION

ESC in a porcine urothelial treatment model results in full-thickness tissue necrosis in bladder, ureter, and renal pelvis at a minimal treatment settings of 5 s/cycle for six cycles. Adiabatic gas expansion may result in fatal pyelovenous gas embolism and collateral organ injury, as seen in both animals receiving treatment to the renal pelvis in this study. These results raise safety concerns for use of ESC as a treatment modality in urothelial tissues with current device settings.

Utility and diagnostic accuracy of ureteroscopic biopsy in upper tract urothelial carcinoma

CONTEXT

Ureteroscopic biopsy is the gold standard for the histopathologic diagnosis of urothelial carcinoma of the upper urinary tract.

OBJECTIVE

To assess the accuracy of endoscopically obtained biopsy samples in diagnosing, grading, and staging urothelial carcinoma and correlate diagnostic findings to biopsy sample size.

DESIGN

We retrospectively reviewed endoscopic biopsies of the ureter, renal pelvis, and ureteropelvic junction from 2008 to 2011. Biopsy diagnoses that were discordant with follow-up pathology and/or ureteroscopic impression were re-reviewed and samples were immunohistochemically analyzed.

RESULTS

Endoscopic biopsies (n = 118) yielded a sensitivity of 85.4% for the ureter (n = 79), 77.8% for the renal pelvis (n = 37), and 100% for the ureteropelvic junction (n = 2). A specificity of 100% for all locations and a diagnostic accuracy of 98.3% were identified. The median sample size was 0.3 cm for true positives, 0.3 cm for true negatives, and 0.2 cm for false negatives with no statistical significance. We found that 87.1% of tumors diagnosed on biopsy had concordant grade and 60.0% had concordant pT stage with follow-up surgical resections (n = 43) and biopsies (n = 24). Biopsy samples with concordant tumor grades (mean = 0.6 cm) compared with follow-up resection were larger than biopsy samples with discordant grades (mean = 0.3 cm) (P = .04).

CONCLUSIONS

Though highly specific, endoscopic biopsy does provide a significant false-negative rate owing to both sampling and diagnostic errors when assessing the upper urinary tract for urothelial carcinoma. Tumor grading is accurate, particularly with larger tissue samples, but tumor staging is unreliable.

The use of a biological model for comparing two techniques of fluoroscopy-guided percutaneous puncture: A randomised cross-over study

Objectives

To develop a new and inexpensive model for training in fluoroscopic puncture into the pelvicalyceal system, and to use this model to compare the learning curve of two fluoroscopic techniques, the ‘eye of the needle’ (EN) and triangulation techniques.

Materials and methods

For the trial we used a commercial plastic model (a shop-window mannequin) in which a bovine kidney, embedded in sponge with a spatial orientation similar to the human, was inserted into the model. The ureter of the animal kidney was connected to contrast fluid. Ten residents and interns were randomised into two groups; group A started the puncture using the EN technique, each member making five attempts, and then five attempts using the triangulation technique, and group B started with triangulation and then used the EN technique.

Results

There was no statistically significant difference between the techniques for the mean (SD) number of trials to make a correct puncture, at 2.68 (1.00) in the EN technique and 2.86 (1.05) in the triangulation technique, or for the duration of each trial, at 523 (189) s for the EN technique and 578 (175) s for the triangulation technique. The fluoroscopy time was less in the EN technique, at 113.9 (48.9) s than for the triangulation method, at 135.8 (42.4) (P < 0.005).

Conclusions

The model was easy to construct and feasible for training. Both techniques had a similar learning curve, with higher fluoroscopy exposure for the triangulation technique.

Significance of ureteroscopic biopsy grade in patients with upper tract urothelial carcinoma

BACKGROUND

The objective of this study was to assess the significance of the ureteroscopic biopsy grade for patients with upper tract urothelial carcinoma (UTUC).

PATIENTS AND METHODS

This study included 40 patients who were diagnosed with a single focus of UTUC by ureteroscopic biopsy and subsequently underwent nephroureterectomy. The significance of the biopsy grade as a predictive factor for pathological outcomes of nephroureterectomy was retrospectively analyzed.

RESULTS

Of these 40 patients, 19 (47.5%) and 21 (52.5%) were diagnosed with low and high grade UTUC, respectively. The ureteroscopic biopsy grade matched the pathological grade of surgically resected specimens in 35 of the 40 cases (87.5%), and there was a significant correlation between the biopsy and pathological grades (p < 0.001). Furthermore, the biopsy grade was also shown to be closely associated with the pathological stage (p < 0.001); that is, only 1 of the 19 patients (5.3%) with biopsy low grade UTUC were pathologically diagnosed as having muscle invasive disease, while 17 of the 21 patients (81.0%) with biopsy high grade UTUC appeared to show tumor invasion into muscle or deeper.

CONCLUSIONS

The grade of UTUC on ureteroscopic biopsy could provide accurate diagnostic information on the final pathology of nephroureterectomy specimens.

Upper tract urothelial carcinoma: current treatment and outcomes

The reference standard treatment of upper tract urothelial carcinoma is open radical nephroureterectomy. Many centers have advocated less-invasive treatment modalities. We reviewed contemporary treatments of upper tract urothelial carcinoma and their outcomes. A MEDLINE search was conducted for all relevant published data during the past 15 years. Endoscopic management is feasible for low-grade disease with strict surveillance protocols. Radical nephroureterectomy remains the reference standard for upper tract urothelial carcinoma. The intermediate-term oncologic outcomes are similar between the laparoscopic and open approaches. Controversies still exist regarding the optimal management of the distal ureter, the utility of topical therapy, and the role of lymphadenectomy.

The effect of tumor location on prognosis in patients with primary ureteral urothelial carcinoma

OBJECTIVES

To investigate the association of tumor location on oncological outcomes in patients treated with radical nephroureterectomy (RNU) for primary ureteral urothelial carcinoma (UC).

MATERIALS AND METHODS

From January 1990 to December 2007, 127 patients with primary solitary ureteral UC who underwent RNU at our institution were included. The patients were divided into 3 groups based on tumor location-proximal, middle, or distal ureter. Patients' medical records were reviewed retrospectively. The clinicopathologic data and oncologic outcomes were compared among the groups.

RESULTS

Of the 127 patients, 40 (31.5%) had tumors in the proximal ureter, 40 (31.5%) in the middle ureter, and 47 (37.0%) in the distal ureter. Patients with distal ureteral UC were more likely to undergo open procedures to manage the bladder cuff (P = 0.005). Other clinical and histopathologic variables were not different among the 3 groups. Comparing the proximal, middle, or distal ureteral UC, bladder recurrence developed in, respectively, 25.0%, 25.0%, and 21.3% cases (P = 0.892); local retroperitoneal recurrence in 2.5%, 12.5%, and 4.3% (P = 0.141); contralateral recurrence in 0%, 0%, and 4.3%(P = 0.177); and distant metastasis in 17.5%, 10.0%, and 4.3% (P = 0.147). Recurrence-free and cancer-specific survival among the 3 groups were not different (P = 0.781 and 0.192, respectively).

CONCLUSIONS

Tumor location cannot be used to predict oncologic outcomes in patients treated with RNU for primary ureteral UC. Therefore, clinical decisions or follow-up protocol should not differ among patients with primary proximal, middle, or distal ureteral UC.

High rate of pathologic upgrading at nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVE

To determine the association between endoscopic biopsy grade and the final pathologic characteristics at nephroureterectomy for upper tract urothelial carcinoma (UTUC). Endoscopic biopsy is an important tool for patients with UTUC because the results can influence the management decisions.

METHODS

We identified 481 patients who had undergone nephroureterectomy for UTUC at the Mayo Clinic from 1995 to 2008. Of these patients, 184 underwent endoscopic cup or brush biopsy before nephroureterectomy. The biopsy tumor grade was then compared with the tumor grade and stage obtained at nephroureterectomy.

RESULTS

Of the 184 patients, 27 (15%) had nondiagnostic biopsy results and 21 (11%) had positive biopsy results with no histologic grade. Of the 24 patients with grade 1 tumors on biopsy, 23 (96%) had the tumor upgraded on the final pathologic examination: 16 (67%) to grade 2 and 7 (29%) to grade 3. Similarly, 23 (40%) of 57 grade 2 tumors on biopsy were upgraded to grade 3 after nephrouretecomy. Only a few patients, 7 (4%) of 184, were found to have a lower histologic grade on the final pathologic examination. The number of patients with invasive UTUC for endoscopic grade 1, 2, and 3 tumors was 9 (38%) of 24, 31 (54%) of 57, and 47 (85%) of 55, respectively.

CONCLUSION

In the context of patients selected for nephroureterectomy, we observed a greater than expected rate of tumor upgrading and invasive disease, particularly in those with low-grade tumors at biopsy. These findings should be considered when electing to use conservative or endoscopic management of low-grade UTUC.

Long-term endoscopic management of upper tract urothelial carcinoma: 20-year single-centre experience

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Endoscopic management of small, low-grade, non-invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long-term survival outcomes of endoscopically-managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow-up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease-specific survival outcomes. The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long-term follow-up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade-stratified analysis of different outcomes, including upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and disease-specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low-grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres.

OBJECTIVE

• To report the long-term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20-year period.

PATIENTS AND METHODS

• Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment. • Outcomes were obtained via retrospective analysis of notes, electronic records and registry data. • Survival outcomes, including overall survival (OS), UTUC-specific survival (disease-specific survival; DSS), upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and progression-free survival, were estimated using Kaplan-Meier methods and grade-stratified differences were analyzed using the log-rank test.

RESULTS

• Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years. • All patients underwent ureteroscopy and biopsy-confirmation of pathology was obtained in 81% (n = 59) of the patients. In total, 14% (n = 10) of the patients underwent percutaneous resection. • Median (range; mean) follow-up was 54 (1-223; 62.8) months. • Upper tract recurrence occurred in 68% (n = 50). Eventually, 19% (n = 14) of the patients proceeded to nephroureterectomy. • The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months.

CONCLUSIONS

• The present study represents one of the largest reported series of endoscopically-managed UTUC, with high pathological verification and long-term follow-up. • Upper-tract recurrence is common, which mandates regular ureteroscopic surveillance. • However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.

Minimally invasive approach in the management of upper- urinary-tract tumours

OBJECTIVE

Nephroureterectomy with bladder cuff excision has been the gold standard treatment for upper tract transitional cell carcinoma (UTTCC) for more than 60 years. However, endoscopic treatment of urothelial tumours of renal pelvis and ureter is gaining acceptance as a conservative treatment modality.

MATERIAL AND METHODS

A review in the English language of the Medline and Pub Med databases was performed using the keywords upper urinary tract transitional cell carcinoma and endoscopic management. There was a particular emphasis on treatment outcomes from published series.

RESULTS

Endoscopic treatment of UTTCC alone for high-grade tumours is not advised owing to high rates of both local recurrence and disease progression, while many authors do not recommend primary endoscopic management of UTTCC in elective situations if pathological analysis and tumour grade cannot be obtained.

CONCLUSION

Endourological management of UTTCC has become an accepted treatment option in highly selected patients, provided long-term close surveillance to detect and treat recurrences is ensured.

High-grade ureteroscopic biopsy is associated with advanced pathology of upper-tract urothelial carcinoma tumors at definitive surgical resection

BACKGROUND AND PURPOSE

Accurate assessment of upper-tract urothelial carcinoma (UTUC) pathology may guide use of endoscopic vs extirpative therapy. We present a multi-institutional cohort of patients with UTUC who underwent surgical resection to characterize the association of ureteroscopic (URS) biopsy features with final pathology results.

PATIENTS AND METHODS

URS biopsy data were available in 238 patients who underwent surgical resection of UTUC. Biopsies were performed using a brush biopsy kit, mechanical biopsy device, or basket. Stage was classified as a positive brush, nonmuscle-invasive (<pT(2)), or muscle invasive (MI; ≥pT(2)). Grade was classified as low or high.

RESULTS

On URS biopsy, 88/238 (37%) patients had a positive brush, 140 (59%) had a diagnosis of non-MI, and 10 (4%) had MI disease. Biopsy results showed low-grade cancer in 140 (59%) and high-grade cancer in 98 (41%). Pathologic evaluation at surgical resection demonstrated non-MI tumors in 140 (59%) patients, MI in 98 (41%), and high-grade disease in 150 (63%). On univariate analysis, high URS biopsy grade was associated with high-grade (positive predictive value [PPV] 92%, P<0.0001) and MI (PPV 60%, P<0.0001) UTUC at surgery. URS biopsy stage, however, was associated with surgical pathology grade (P=0.005), but not MI (P=0.16) disease. On multivariate analysis, high URS grade, but not biopsy stage, was associated with high final pathology grade (hazard ratio [HR] 16.6, 95% confidence interval [CI] 7.0-39.5, P<0.0001) and MI UTUC (HR 3.6, 95% CI 2.1-6.8, P<0.0001).

CONCLUSION

High URS biopsy grade, but not stage, is associated with adverse tumor pathology. This information may play a valuable role for risk stratification and in the appropriate selection of endoscopic management vs surgical extirpation for UTUC.

Endoscopic management of upper tract transitional cell carcinoma

Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The “gold standard” management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.

Inadequacy of biopsy for diagnosis of upper tract urothelial carcinoma: implications for conservative management

OBJECTIVE

To report changes in grade and stage between initial diagnostic and repeat biopsies or resection for urothelial carcinoma (UTUC) and investigate the consequences for endoscopic management. Ureteroscopic management of upper tract UTUC is an alternative to nephroureterectomy, which is less invasive and preserves renal function. However, concerns about potential understaging, inaccurate grading, incomplete resection, lack of effective tertiary chemoprevention, and need for ureteroscopic surveillance limits it appeal.

METHODS

Clinicopathological records of patients with UTUC treated at our institution were reviewed. Fifty-six patients with a histologic diagnosis of UTUC and 2 or more consecutive biopsies or biopsy followed by surgical resection were included, resulting in 65 biopsy specimens.

RESULTS

The median interval between diagnostic biopsy and subsequent biopsy or resection was 6 weeks (range, 1 week to 60 months). Change in grade from the diagnostic biopsy occurred in 24 of 65 biopsies (37%), including 9 in which diagnosis changed from low to high grade. Change in the stage from the diagnostic biopsy occurred in 25 of 65 biopsies (38%). Overall, 24 (43%) patients were reclassified from low-grade, noninvasive disease to high-grade and/or invasive disease.

CONCLUSION

A change in grade and/or stage from the diagnostic biopsy occurred in more than one third of patients with UTUC managed conservatively. Because of the short median time interval between biopsies, this finding likely represents variability in tumor sampling on biopsy. Because of the concerns of undergrading and understaging, appropriate patient selection and vigilant endoscopic surveillance are mandatory for UTUC managed endoscopically.

Transurethral endoscopic treatment of patients with upper tract urothelial carcinomas using neodymium-YAG and/or holmium-YAG laser ablation

OBJECTIVE

To report our experience of treating patients with original and recurrent upper tract urothelial carcinomas (UC) using endoscopic lasers, with holmium-YAG and/or neodymium-YAG laser ablation, and for whom tumour stage and grade were obtained by endoscopic biopsy.

PATIENTS AND METHODS

From March 2003 to March 2007, 15 patients with upper tract UC were treated with endoscopic laser ablation as the primary management. Patients were followed up by intravenous urography, computed tomography, urine cytology and/or ureteroscopic surveillance at 3- to 12-month intervals. The median (range) follow-up was 25.5 (13-51) months.

RESULTS

Of the 15 patients, five had an upper tract recurrence during the follow-up. Three of these were treated with total nephroureterectomy and two had a progression in tumour stage or grade. Three patients had residual tumours; they were treated with repeated endoscopic laser treatments and had no recurrence over a median (range) of 24 (13-26) months. The renal preservation rate was 12/15 and the local recurrence rate was six/15 after the initial endoscopy. The median operative duration and tumour size were 60 min and 10 mm, respectively.

CONCLUSION

Patients with low-grade and -stage disease and normal contralateral kidneys also benefit from this approach, if there is an adequate endoscopic biopsy. As the operative duration tended to be associated with the maximum tumour size, this treatment is potentially available for a maximum tumour size of <4 cm; if the tumour is <4 cm surgery will require <120 min.

Bladder recurrence after surgery for upper urinary tract urothelial cell carcinoma: frequency, risk factors, and surveillance

OBJECTIVE

To highlight the main risk factors for metachronous bladder recurrence after treatment of an upper urinary tract urothelial cell carcinomas (UUT-UCCs) based on the recent literature.

MATERIALS AND METHODS

Data on urothelial malignancies after UUT-UCCs management in the literature were searched using MEDLINE and by matching the following key words: urinary tract cancer; bladder carcinomas, urothelial carcinomas, upper urinary tract, renal pelvis, ureter prognosis, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, cystectomy, nephroureterectomy, minimally invasive surgery, recurrence, and survival.

RESULTS

No evidence level 1 information from prospective randomized trials was available. A range of 15% to 50% of patients with a UUT-UCC will subsequently develop a metachronous bladder UCC. Intraluminal tumor seeding and pan-urothelial field change effect have both been proposed to explain intravesical recurrences. In most cases, bladder cancer arises in the first 2 years after UUT-UCC management. However the risk is lifelong and repeat episodes are common. The identification of variables that allow accurate risk stratification of UUT-UCC patients with regards to future bladder relapse is disappointing. No factors have been identified to date that can reliably predict bladder recurrences. A history of bladder cancer prior to UUT-UCC management and upper tract tumor multifocality are the only frequently reported clinical risk factors among current literature.

CONCLUSION

Prior histories of bladder cancer and upper tract tumor multifocality are the most frequently reported risk factors for bladder tumors following UUT-UCCs. Surveillance regimen is based on cystoscopy and on urinary cytology for at least 5 years.

Ureteroscopic management of upper tract transitional cell carcinoma and ureteropelvic obstruction

Introduction:

Technological advances have increased the application of the endoscopic management of upper tract transitional cell carcinoma (TCC) and ureteropelvic junction obstruction (UPJO).

Materials and Methods:

Published, peer-reviewed articles on endoscopic treatment of upper tract TCC and UPJO were identified using the MEDLINE database.

Results:

Although nephroureterectomy remains the gold standard for upper tract TCC treatment, low-grade, low-stage and small tumors, especially in patients with solitary kidneys or poor renal function can be managed with encouraging success rates, despite the considerable recurrence rate. Endoscopic alternatives to pyeloplasty for UPJO can be used especially in cases with absence of crossing vessels, stricture length less than 1.5 cm, severe hydronephrosis and renal function less than 30%.

Conclusion:

Proper patient selection is critical for the successful endoscopic management of treatment of upper tract TCC and UPJO.