Ureteroscopic biopsy: technique and specimen preparation

Diagnostic ureteroscopy for upper tract urothelial carcinoma: friend or foe?

Introduction

The European Association of Urology guidelines recommend offering kidney-sparing surgery (KSS) as a primary treatment option to patients with low-risk tumours. Cystoscopy, urinary cytology, and computed tomography urography (CTU) do not always allow correct disease staging and grading, and sometimes there is even a lack of certainty regarding the diagnosis of UTUC. Diagnostic ureteroscopy (d-URS) may therefore be of crucial importance within the diagnostic framework and fundamental in establishing the appropriate therapeutic approach.

Evidence acquisition and synthesis

A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of interventions (ROBINS-I). Overall, from 3791 identified records, 186 full-text articles were assessed for eligibility. Finally, after a quantitative review of the selected literature, with the full agreement of all authors, 62 studies were considered relevant for this review.

Results

CTU has a sensitivity and specificity for UTUC of 92% and 95% respectively, but is not able to detect small or flat lesions with adequate accuracy. The sensitivity of voided urinary cytology for UTUC is around 67–76% and ranges from 43% to 78% for selective ureteric urine collection. As no technique offers a diagnosis of certainty, d-URS can allow an increase in diagnostic accuracy. In the present review the pros and cons of d-URS were analysed. This technique may provide additional information in the selection of patients suitable for neoadjuvant chemotherapy or KSS, distinguishing between normal tissue and low- and high-grade UTUC thanks to the emerging technologies.

Conclusions

Information obtainable from d-URS and ureteroscopic-guided biopsy can prove extremely valuable when the diagnosis of UTUC is doubtful or KSS is being considered. Notwithstanding concerns remain regarding the potential risk of bladder recurrence, cancer dissemination, and/or delay in radical treatment.

Abbreviations: CLE: confocal laser endomicroscopy; CSS: cancer-specific survival; CTU: CT urography; d-URS: diagnostic ureteroscopy; EAU: European Association of Urology; HR: hazard ratio; IMAGE1S: Storz professional imaging enhancement system; IVR: intravesical recurrence; KSS: kidney-sparing surgery; MFS: Metastasis-free survival; NAC: neoadjuvant chemotherapy; NBI: narrow-band imaging; OCT: optical coherence tomography; RFS: Recurrence-free survival; RNU: radical nephroureterectomy; ROBINS-I: Risk of Bias in Non-randomized Studies of interventions; URS(-GB): Ureteroscopy(-guided biopsy); UTUC: upper tract urothelial carcinoma; UUT: upper urinary tract

Endoscopic management of upper tract urothelial carcinoma-tips and tricks

Ureteroscopic methods have been rapidly evolving in the last several decades. With advances in flexible devices, optics and laser technologies, the endourologic surgeon has now the tools to treat high-volume tumors, in difficult locations, with good oncologic outcome. This makes radical nephroureterectomy unnecessary in some cases. Endoscopy in the setting of UTUC will surely continue to evolve and become applicable to a wider selection of patients. In this review we describe the surgical technique and provide tips and tricks which we use in our practice of endoscopic retrograde treatment of upper-tract urothelial carcinoma.

Cytologic processing of ureteral microbiopsies is associated with higher sensitivity for detection of urothelial carcinoma compared with conventional biopsy processing

INTRODUCTION

Because of the high rates of false-negative or nondiagnostic ureteral Piranha microbiopsies associated with low cellularity, we assessed the effect of processing these using cytology.

MATERIALS AND METHODS

We included 2 groups of 44 consecutive microbiopsies processed from formalin as a standard surgical biopsy and 22 processed by cytology. All samples were from the ureter or renal pelvis or calyx. The cytology samples were collected in alcohol-based media and were prepared with a Cellient cell block only (n = 9) or with a Cellient cell block for the visible particles, together with ThinPrep, to capture the remaining desquamated cells (n = 13).

RESULTS

Malignancy was diagnosed in 5 of 44 conventionally processed microbiopsies (11%) compared with 14 of 22 cytologically processed microbiopsies (64%; P < 0.001), including 1 case with invasion. Nineteen site-matched biopsies from 2 patients had undergone both cytologic and surgical processing, with 8 of 8 cytologically processed biopsies diagnosed as malignant. None of the 11 surgically processed biopsies from the same patients matched for site were diagnosed as malignant. Of the 11, 2 (18%) were suspicious for high-grade urothelial carcinoma and 6 (55%) were considered atypical. Increased sensitivity from cytologic processing appears related to increased cell recovery; large numbers of well-preserved urothelial cells were identified in the ThinPrep (range, 1000-25,000 cells/slide), and a nonsignificant trend was found toward increased urothelium (defined as >200 cells/profile) in the Cellient cell blocks (14 of 22 [64%]) compared with the histologic biopsies (17 of 44 [39%]; P = 0.070).

CONCLUSIONS

Cytologic processing of ureteral microbiopsies showed superior sensitivity for detecting high-grade urothelial carcinoma, apparently owing to the increased cellular recovery.

Ureteroscopic Management of Large ≥2 cm Upper Tract Urothelial Carcinoma: A Comprehensive 23-Year Experience

OBJECTIVE

To evaluate the effectiveness of ureteroscopy (URS) with laser ablation as an alternative treatment for upper tract urothelial carcinoma (UTUC) lesions larger than 2 cm. Traditionally, patients with large UTUC are treated with radical nephroureterectomy (RNU). However, in patients with pre-existing renal disease, a solitary kidney, or those who decline RNU, management of UTUC may prove challenging METHODS: An institutional database review identified 80 patients with biopsy proven low-grade UTUC who had at least one lesion larger than 2 cm. We collected clinical data including demographics, operative parameters, and pathologic features. Follow-up for all patients was standardized and included cystoscopy and URS every 3 months until clear, every 6 months through the fifth year, and yearly thereafter. We calculated rates of recurrence, progression, and overall survival.

RESULTS

In total, 86 unique lesions ≥2cm were identified in the 80 qualifying patients; mean tumor size was 3.04 cm. Median follow-up was 43.6 months. During follow-up of patients treated curatively, 90.5% of tumors had ipsilateral recurrence and 31.7% progressed in grade at a median of 26.3 months. RNU was performed in 16 patients (20%); mean time to surgery was 23.2 months. Overall survival was 75%, and cancer specific survival was 84% at 5-year follow-up.

CONCLUSION

Under strict surveillance, ureteroscopic management of large (≥ 2cm) UTUC lesions is a viable treatment alternative to RNU. While recurrence is common, URS can potentially preserve renal units in patients with large lesions.

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.

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.

Ureteroscopic biopsy of upper tract urothelial carcinoma: comparison of basket and forceps

PURPOSE

To compare two different biopsy devices for upper tract urothelial carcinoma (UTUC) and evaluate the pathologic result obtained by these devices.

PATIENTS AND METHODS

From January 2008 to December 2010, 414 ureteroscopies were performed and 504 biopsies were taken for evaluation of UTUC. Two biopsy devices were compared: 2.4F stainless steel flat wire basket and 3F cup biopsy forceps. The effect of the biopsy device on obtaining an adequate pathologic specimen was evaluated using univariate and multivariate binary logistic regression analysis. We also investigated whether tumor grade determination was affected by the biopsy device among patients with a diagnostic biopsy.

RESULTS

Diagnosis was successful in 63% and 94% in the forceps and basket groups, respectively (P < 0.0001). Among biopsies with a definite diagnosis of UTUC, specific grade was determined in 80% and 93% in the forceps and basket groups, respectively (P = 0.033). In subgroup analysis of tumors larger than 10 mm in diameter, diagnosis was obtained in 80% and 94% in the forceps and basket groups, respectively (P = 0.037). Cytologic evaluation was found to increase diagnostic rates.

CONCLUSIONS

The stainless steel flat wire basket was shown to be superior to the 3F cup biopsy forceps in terms of obtaining tissue diagnosis and providing specific grade.

Ureteroscopic management of upper tract urothelial carcinoma (UTUC) in patients with Lynch Syndrome (hereditary nonpolyposis colorectal cancer syndrome)

OBJECTIVES

To report our experience with ureteroscopic laser ablation of upper tract urothelial carcinoma (UTUC) in patients with Lynch Syndrome (LS), as defined by a documented germline mutation in the MSH-2 gene. To increase awareness among urologists about UTUC in this unique patient population and refer to genetic counselling when appropriate.

PATIENTS AND METHODS

Demographic, clinical and pathological data on 13 consecutive patients with UTUC and documented MSH-2 mutation comprising 15 involved renal units were retrospectively collected. Ureteroscopic evaluations involved biopsy and laser treatment with combination holmium/neodymium yttrium aluminum garnet (YAG) lasers. Tumours were graded from 1 to 3 according to the 1973 World Health Organisation classification by a single pathologist evaluating cell block preparations.

RESULTS

The mean patient age at initial presentation was 56.5 years, with six of 13 patients having metachronous bilateral UT disease. The mean follow-up was 59 months with a mean number of surveillances of 12. Of 15 affected renal units, 10/15 (67%) of initial tumours involved the ureter with mean lesion size of 17.5 mm, while five of 15 (33%) involved the intrarenal collecting system with mean lesion size of 25 mm. Ureteroscopy cleared 13/15 (87%) lesions and four of those 13 (31%) needed staged procedures. Renal preservation rate was 14/15 (93%) with one nephroureterectomy and one segmental ureterectomy performed. One patient developed metastatic UTUC after 40 months surveillance. No patient presented with bladder tumours but seven of the 13 (54%) developed them within 10 months of the initial ureteroscopy.

CONCLUSIONS

Patients with LS who develop UTUC present at younger ages and appear to be more likely to have bilateral UT disease over their lifetimes vs sporadic UTUC patients. Ureteroscopic laser ablation offers a good renal preservation rate with reasonable cancer control in patients willing to undergo endoscopic surveillance. Development of new bladder tumours is common.

Oral 5-aminolevulinic acid in simultaneous photodynamic diagnosis of upper and lower urinary tract transitional cell carcinoma - a prospective audit

What's known on the subject? and What does the study add? The idea of using photosensitizing agents to enhance visualization of cancer tissue dates back to 1900. 5-Aminolevulinic acid (5-ALA) was first suggested for photodynamic diagnosis (PDD) of transitional cell cancer (TCC) of the bladder in 1992. Since then, PDD with intravesical application of 5-ALA or its ester hexaminolevulinate (Hexvix) has proven to be superior over standard white-light cystoscopy in detection of carcinoma in situ and dysplasia as well as enhancing margins of TCC. PDD of upper urinary tract TCC is under-studied because of trouble with delivery of the photosensitizer. Fluorescence after oral 5-ALA was initially reported in 1956. Oral 5-ALA for photodynamic therapy was suggested for upper urinary tract TCC in 1998 and for refractory non-muscle invasive bladder cancer in 2001. A study in 2012 on oral and intravesical application of 5-ALA for bladder PDD showed no difference in diagnostic accuracy for each modality. To our knowledge our series is the first report on use of oral 5-ALA for PDD in detection of upper urinary tract tumours. We published our initial results in 2010. We think that our recent audit is quite encouraging. PDD ureterorenoscopy resulted in detection of additional urothelial tumours that could have been missed by the conventional white-light endoscopy. We suggest that this technique should be used in large multicentre trials to replicate our results.

OBJECTIVE

• To evaluate the diagnostic accuracy of photodynamic diagnostic ureterorenoscopy after oral administration of 5-aminolevulinic acid (5-ALA) for upper urinary tract urothelial cancers.

PATIENTS AND METHODS

• In this audit, twenty-six patients underwent thirty-nine procedures (cystoscopy/ureterorenoscopy) following oral administration of 5-ALA for photodynamic diagnosis (PDD). • Twenty mg/kg body weight of 5-ALA was given orally 3-4 hours prior to the planned endoscopic visualisation. • Following standard white light cystoscopy and ureterorenoscopy, photodynamic diagnostic endoscopy was performed using D-light system (Olympus PDD cystoscope and 7.5Fr KARL STORZ PDD Flex-X ureterorenoscope) to detect fluorescence. • Biopsies were carried out from all suspicious areas, noting if lesions were detected under white or blue light or both.

RESULTS

• A total of sixty-two biopsies were performed for suspicious urothelial lesions (35 bladder, 26 ureter/renal pelvis and 1 from prostatic urethra). • Of the 35 bladder biopsies, 11 lesions were seen under both white and blue light and 91% of these were malignant. • While 24 (68.5%) biopsies were taken from lesions seen only under blue light and 45.8% of these were malignant. • Similarly, of the 26 ureteric/renal pelvicalyceal biopsies, 11 were concurrent in both white and blue light and 100% of these were malignant. • While 10 (38.5%) lesions were seen only under blue light and 70% of these were malignant.

CONCLUSIONS

• Photodynamic diagnosis using oral 5-ALA is safe and feasible with additional advantages of detecting lesions not visualised with conventional white light endoscopy. • This may translate into more complete treatment thereby decreasing subsequent recurrences and possibly progression of the upper urinary tract urothelial cancers.

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

Objective

To assess the diagnostic accuracy of photodynamic diagnostic (PDD) ureterorenoscopy for detecting upper-urinary tract transitional cell carcinoma (UUT-TCC) in our initial 3 years, and compare the results with that of white light ureterorenoscopy (WLU).

Patients and methods

Between August 2007 and March 2010, 32 patients underwent PDD flexible ureterorenoscopy for UUT-TCC. Oral 5-aminolaevulinic acid (5-ALA) was used as the photosensitiser. The sensitivity, specificity and detection rate of PDD were calculated.

Results

The sensitivity, specificity, positive and negative predictive values of PDD for detecting abnormal tissue were 96%, 100%, 100% and 88%, compared to the results of WLU of 80%, 86%, 95% and 55%, respectively. PDD was able to detect 96% (24/25) of the abnormal tissue and 96% (21/22) of cancerous tissue, while WLU detected 80% (20/25) of abnormal tissue and 91% (20/22) of the tumour tissue. Three patients of the 32 (10%) developed side-effects related to 5-ALA; two patients developed a facial-skin photosensitive reaction and one developed hypotension. All were treated conservatively, with no long-term effects.

Conclusion

PDD can be used safely in the UUT, and with a higher sensitivity, specificity and detection rate than standard WLU for detecting UUT tumours.

Ureteroscopic laser treatment of upper urinary tract neoplasms

BACKGROUND

Endoscopic management of upper urinary tract transitional cell carcinoma has assumed an important role in diagnosis and treatment. The introduction of small diameter rigid and flexible ureteroscopes has permitted access to the upper tract. Biopsy techniques have been developed for accurate diagnosis, and the addition of lasers has given the urologists an excellent tool for treatment.

METHODS

Medical literature available relative to the endoscopic laser treatment of upper tract neoplasms has been reviewed.

RESULTS

Ureteroscopic treatment has been characterized by good success with high recurrence rates, both in the upper tract and in the bladder. Bladder recurrence rates are similar to those seen after surgical treatment of upper tract tumors. Surveillance has been ureteroscopic since the other diagnostic options are inadequate. The holmium and neodymium:YAG lasers are the devices most commonly used now for the endoscopic treatment of upper tract tumors.

CONCLUSION

Ureteroscopic treatment of upper tract neoplasms usually with ablation and resection using the neodymium and holmium:YAG lasers is a current acceptable procedure. This should be considered as one of the options in tumor treatment.

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.

Advanced intrarenal ureteroscopic procedures

The role of flexible ureteroscopy in the management of intrarenal pathology has undergone a dramatic evolution, powered by improvements in flexible ureteroscope design; deflection and image quality; diversification of small, disposable instrumentation; and the use of holmium laser lithotripsy. This article reviews the application of flexible ureteroscopy for advanced intrarenal procedures.

Ureteroscopic surgery: changing times and perspectives

Ureteroscopy developed as an extension of cystoscopic techniques into the upper urinary tract with smaller, rigid, and flexible endoscopes. Smaller working instruments have made therapeutic procedures possible. Ureteroscopy has become the technique of choice to diagnose and treat benign essential hematuria and has a major role in treating ureteropelvic junction obstruction, upper tract neoplasms, and calculi. Finally, there is a need for smaller and more effective endoscopes and working devices.

Usefulness of Ureteropyeloscopy for diagnosis of upper urinary tract tumors

BACKGROUND

Upper urinary tract tumors have historically been diagnosed using urinary cytology examination and radiography. As the technique and instrumentation of ureteroscopic inspection and biopsy have advanced, ureteroscopic examination has become more routine. We studied the applicability and safety of using ureteropyeloscopy to diagnose upper urinary tract tumors.

PATIENTS AND METHODS

Between January 1994 and October 1999, 50 patients at Kobe University Hospital underwent ureteropyeloscopy for suspected upper urinary tract tumors.

RESULTS

The sensitivity values of radiography, urinary cytology, and ureteroscopy were 96%, 60%, and 92%, respectively. The specificity values of the three procedures examination were 12%, 84%, and 88%, respectively. No major complications or dissemination of malignant cells were evident.

CONCLUSION

Ureteroscopic examination is a safe, sensitive, and specific means of detecting upper urinary tract tumors.

Ureteroscopic surgery for upper tract transitional-cell carcinoma: complications and management

In some patients with small low-grade transitional-cell carcinoma of the ureter, the lesion can be treated ureteroscopically with the laser or electrocoagulation. Patients must be compliant with lifelong frequent surveillance. Surgical complications such as ureteral perforation and stricture are uncommon. The authors provide advice on technique and on preventing and managing complications.

Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys

PURPOSE

The standard treatment for upper tract transitional cell carcinoma in patients with a normal contralateral kidney is nephroureterectomy with a bladder cuff or segmental ureterectomy. We evaluate whether ureteroscopic tumor resection with vigilant surveillance is a safe alternative in select patients.

MATERIALS AND METHODS

Patients with isolated upper tract filling defects on an excretory urogram and a normal contralateral kidney were diagnosed ureteroscopically with papillary low intermediate grade appearing transitional cell carcinoma. Biopsies of the lesions were obtained, and the tumors were treated with laser ablation or electrofulguration in the same sitting. Patients with cytopathological results of high grade transitional cell carcinoma underwent nephroureterectomy. Surveillance consisted of ureteroscopy every 3 months until tumor-free and ureteroscopy every 6 months thereafter.

RESULTS

Between 1989 and 1998, 23 patients with normal creatinine (mean 1.0, range 0.7 to 1.6) underwent ureteroscopic resection of unilateral upper tract transitional cell carcinoma. On initial biopsy 22 tumors were grade 1 or 2 and 1 was grade 2 to 3. After the primary tumor was treated 8 (35%) patients remained tumor-free and 15 (65%) had multiple recurrences, which were treated ureteroscopically. Mean followup was 35 months (range 8 to 103 months). All 23 patients are alive without evidence of disease progression. At last followup 4 patients (17%) had persistent disease, 4 (17%) elected to undergo nephroureterectomy and 15 (65%) are free of ipsilateral disease for a mean duration of 17 months (range 6 to 77).

CONCLUSIONS

Ureteroscopic treatment of focal low intermediate grade superficial upper tract transitional cell carcinoma is a safe alternative to nephroureterectomy in select patients when vigilant ureteroscopic followup is used.

Ureteroscopic approach to upper-tract urothelial tumors

Transitional-cell carcinoma (TCC) of the upper urinary tract has traditionally been managed by nephroureterectomy, whereas nephron-sparing surgery has been reserved for those few patients with solitary kidneys or bilateral lesions. However, with the introduction of improved diagnostic and therapeutic technology, including smaller ureteroscopes and working instruments, and the concomitant ease of surveillance, ureteroscopic treatment of upper-tract urothelial tumors has become a reasonable alternative to open operative intervention in patients requiring conservative management. Furthermore, as preoperative grading and staging have improved, ureteroscopic treatment of upper-tract urothelial tumors is assuming an increasingly important role in the management of some patients who might have otherwise been treated with a nephroureterectomy. The technique of ureteroscopic resection is described in detail.

Ureteroscopic and radiographic imaging of the upper urinary tract

Direct endoscopic viewing of the upper urinary tract offers multiple benefits, including recognition and diagnosis, and also permits unsurpassed accuracy in positioning working instruments for biopsy and treatment. We have demonstrated the normal and abnormal endoscopic findings within the upper urinary tract in patients who were treated ureteroscopically for numerous indications, including calculi, filling defects, or ureteral obstruction. Small (7 to 7.5F) rigid and flexible ureteroscopes were employed in all patients. Selected endoscopic images of the subject lesions were photographed using a 35-mm camera with an endoscopic zoom lens and ISO-400 film. Endoscopic findings are illustrated in 13 patients, with case summaries in 11. Selected radiographic and endoscopic images show the essential features in each case and demonstrate the value of ureteroscopic examination.