Correlation between the timing of diagnostic ureteroscopy for upper tract urothelial cancer and intravesical recurrence after radical nephroureterectomy

Objective

We aimed to evaluate the effect of the timing of diagnostic ureteroscopy (URS) on intravesical recurrence (IVR) following radical nephroureterectomy (RNU).

Patients and methods

The clinical data of 220 patients with upper tract urothelial carcinoma (UTUC) treated with RNU at our center from June 2010 to December 2020 were retrospectively analyzed. According to the timing of the URS, all patients were divided into three groups: the no URS group, the 1-session group (diagnostic URS immediately followed by RNU), and the 2-session group (RNU after diagnostic URS). Additionally, we analyzed IVR-free survival (IVRFS) using the Kaplan-Meier and Cox proportional regression methods.

Results

The median follow-up period of these 220 patents was 41 (range: 2-143) months. Among them, 58 patients developed IVR following RNU. Kaplan-Meier curve displayed a significantly higher IVR rate in both treatment groups than in the no-URS group (p=0.025). In the subgroup of patients with renal pelvis cancer, the incidence of IVR was significantly higher in both treatment groups than in the group without URS (p=0.006). In univariate Cox proportional regression analysis, the two treatment groups were risk factors for IVR compared to the no-URS group [p=0.027, hazard ratio (HR): 1.93, 95% confidence interval (CI): 1.08-3.46]. The two-stage group (p=0.032, HR: 1.98, 95% CI: 1.08-3.65), positive urine pathology (p<0.001, HR: 8.12, 95% CI: 3.63-18.15), adjuvant chemotherapy (p<0.001, HR: 0.20, 95% CI: 0.10-0.38), and positive margin (p<0.0001, HR: 7.50, 95% CI: 2.44-23.08) were all identified as independent predictors in the multivariate.

Conclusion

This study revealed that delayed RNU following diagnostic URS may increase the risk of postoperative IVR in patients with UTUC, preoperatively positive uropathology, and positive surgical margin were risk factors for IVR after RNU, while early postoperative chemotherapy may effectively prevent IVR. Delay of RUN after URS could increase the risk of IVR.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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.

Immunoglobulin G4-related Disease of the Genitourinary System: Spectrum of Imaging Findings and Clinical-Pathologic Features

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterized by focal or diffuse organ infiltration of IgG4-bearing plasma cells. The diagnosis of IgG4-RD is based on a combination of clinical, serologic, radiologic, and histopathologic findings. IgG4-RD has been reported to affect almost all organ systems. The kidney is the most frequently involved of the genitourinary organs. The most common renal manifestation of IgG4-RD is IgG4-RD tubulointerstitial nephritis, followed by membranous glomerulonephropathy and, less frequently, obstructive nephropathy involving the renal pelvis, ureter, or retroperitoneum. Renal parenchymal lesions may appear as multiple nodular lesions, diffuse patchy infiltrative lesions, or a single nodular lesion. Multiple small nodular cortical lesions are the most common imaging findings of IgG4-RD involving the kidney. Renal pelvic, sinus, or perinephric lesions can also occur. IgG4-RD involvement of other genitourinary organs including the ureter, bladder, urethra, and male and female reproductive organs is rare compared with kidney involvement but may show variable imaging findings such as a localized mass within or surrounding the involved organ or diffuse enlargement of the involved organ. Imaging findings of IgG4-RD involving the genitourinary system are nonspecific but should be differentiated from inflammatory and neoplastic lesions that mimic IgG4-RD. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Retrograde pyelography before radical nephroureterectomy for upper tract urothelial carcinoma is associated with intravesical tumor recurrence

Purpose:

To investigate the association between preoperative retrograde pyelography (RGP), conducted to evaluate upper tract urothelial carcinoma (UTUC), and intravesical recurrence (IVR) after radical nephroureterectomy (RNU).

Materials and Methods:

Of 114 patients that underwent RNU, 72 patients without preoperative ureteroscopy and a history of bladder tumor were selectively enrolled. Variables associated with IVR were identified.

Results:

RGP was performed at a mean duration of 24.9 days prior to RNU in 41 (56.1%) of study subjects. During the mean follow-up period of 64.5 months, IVRs were identified in 32 (44.4%) patients at 22.3±18.8 (mean±SD) months after RNU. Despite similar tumor characteristics in the RGP and non-RGP groups, the incidence of IVR was considerably higher in the RGP group (63.4%) than in the non-RGP group (19.4%, p <0.001). The following variables differed significantly between the IVR and non-IVR groups: age (64.6±8.51 vs. 59.6±9.65 years), tumor location (lower or upper; 53.1% vs. 20%), tumor invasiveness (> pT2; 53.1% vs. 17.5%), preoperative hemoglobin (12.8±1.36 vs. 13.9±1.65), preoperative creatinine (1.29±0.32 vs. 1.11±0.22), and preoperative RGP (81.3% vs. 37.5%), respectively. Multivariate Cox regression model showed that tumor location (p=0.020, HR=2.742), preoperative creatinine level (p=0.004, HR=6.351), and preoperative RGP (p=0.045, HR=3.134) independently predicted IVR.

Conclusion:

Given the limitations of retrospective single-center series, performance of RGP before RNU was shown to have a negative effect on IVR after surgery.

Who needs further evaluations to diagnose upper urinary tract urothelial cancers among patients with abnormal findings by enhanced CT?

Objective

We evaluated who would need further evaluations such as retrograde pyelography (RP) and/or ureteroscopy to diagnose upper urinary tract urothelial cancers (UUTUCs) when abnormal findings for the upper urinary tract (UUT) were detected by enhanced computed tomography (CT).

Methods

We retrospectively analyzed 125 patients who underwent enhanced CT for various reasons and had abnormal findings for the UUT. Patients whose tumors were suspected to be of extraureteral origin were excluded. All patients received RP and/or ureteroscopy to evaluate the UUTUCs.

Results

The median age of the 125 patients was 70 years and gross hematuria (26.4%) was the most frequently observed symptoms. RP, ureteroscopy and both were performed for 121, 59 and 55 patients, respectively. CT revealed tumor-like lesions in 58 patients and the other patients had non-tumor-like lesions. UUTUCs were found in 43 (34.4%) of the 125 patients. All of them had tumor-like lesions on CT. In 58 patients who had tumor-like lesions on CT, univariate and multivariate analyses revealed that tumor diameter and tumor enhancement were significant predictive factors for UUTUCs. ROC curve analysis of enhanced CT to diagnose UUTUCs revealed that a tumor diameter of 18 mm was the best cutoff point. The sensitivity, specificity and accuracy were 90.0%, 98.8% and 92.7% for RP and 95.5%, 100% and 97.1% for ureteroscopy, respectively. Both of them had high sensitivity, specificity and accuracy.

Conclusion

We should decide to evaluate the UUT according to the tumor diameter on enhanced CT. When we evaluate the UUT in patients with tumor diameters of less than 20 mm, ureteroscopy is recommended.

Diagnostic outcome of ureteroscopy in urothelial carcinoma of the upper urinary tract: Incidence of later cancer detection and its risk factors after the first examination

Background

To determine the incidence of later cancer detection and its risk factors after the first diagnostic ureteroscopy.

Methods

One hundred and sixty-six patients undergoing diagnostic ureteroscopy based on the suspicion of urothelial carcinoma of the upper urinary tract (UC of the UUT) between 1995 and 2012 were included. We examined the diagnostic outcome of the initial ureteroscopy. Thereafter, we collected follow-up data on patients who had not been diagnosed with UC of the UUT at the first examination, and evaluated the incidence of later cancer detection and its risk factors using Cox hazard models.

Results

Of the 166 patients, 76 (45.8 %) were diagnosed with UC of the UUT at the first diagnostic ureteroscopy. The remaining 90 (54.2 %) were diagnosed with other malignancies (n = 22), non-malignant disorders (n = 18), or without disorders (n = 50). Of these 90 patients, follow-up data were available in 65 patients (median: 41 months, range: 3–170). During the follow-up, carcinoma was detected in 6 patients (6/65, 9.2 %) at a median of 43.5 months (range: 10–59). Episodes of gross hematuria (p = 0.0048) and abnormal cytological findings (p = 0.0335) during the follow-up and a male sex (p = 0.0316) were adverse risk factors.

Conclusion

Later cancer detection of UC of the UUT was not uncommon after the first examination. The risk analysis revealed the aforementioned characteristics.

Correlation Between the Timing of Diagnostic Ureteroscopy and Intravesical Recurrence in Upper Tract Urothelial Cancer

To identify the effects of diagnostic ureteroscopy on intravesical recurrence, 104 patients who had undergone radical nephroureterectomy were analyzed. The number of patients with intravesical recurrence was 34 (32.6%) at a mean of 37 months. Multivariate Cox model analysis revealed that delayed nephroureterectomy after diagnostic ureteroscopy were independent predictive factors for intravesical recurrence.

BACKGROUND

The purpose of this study was to evaluate the effects of the timing of diagnostic ureteroscopy (URS) relative to radical nephroureterectomy (RNU) on intravesical recurrence (IVR).

PATIENTS AND METHODS

We retrospectively evaluated 104 patients who had undergone RNU for upper tract urothelial cancer (UTUC) at a single tertiary referral center between March 2003 and December 2012. All patients were divided depending on the timing of diagnostic URS: the no URS group (30 patients, no URS), 1-session group (33 patients, diagnostic URS immediately followed by RNU), and 2-session group (41 patients, RNU after diagnostic URS at a median time of 5 days). We analyzed for IVR-free survival using the Kaplan-Meier and Cox proportional regression methods.

RESULTS

Of the 104 patients, 34 (32.6%) developed subsequent IVR at a mean interval of 7.2 months. The Kaplan-Meier curve showed that the IVR rate was significantly greater in the 2-session group than in the other groups (P = .004). Univariate analysis indicated no effect on IVR in the 1-session group compared with the no URS group (hazard ratio [HR], 95% confidence interval [CI] 1.58; 0.517-4.833). However, the 2-session group had a significantly greater number of patients with IVR than the no URS group (HR, 3.82; 95% CI 1.438-10.131). Multivariate Cox proportional analysis revealed that the 2-session group was an independent predictor of IVR in UTUC patients (HR, 3.61; 95% CI 1.039-12.557).

CONCLUSION

Delay of RNU after diagnostic URS significantly increased the risk of IVR in UTUC patients.

Fluorodeoxyglucose positron emission tomography/computed tomography for diagnosis of upper urinary tract urothelial carcinoma

BACKGROUND

The purpose of this study was to assess the ability of fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) to detect upper urinary tract urothelial carcinomas (UTUC) compared with pathological examination of tissues obtained by ureteroscopic biopsy and split cytologic analysis of urine obtained after retrograde pyelography.

METHODS

Clinicopathological records of patients at our institution were retrospectively reviewed. Fifty patients with clinically suspected UTUC, who were histologically diagnosed by nephroureterectomy, partial ureterectomy, or endoscopic biopsy, were included. The patient cohort included 42 men and 8 women, with a median age of 73 (range 54-92) years.

RESULTS

Only 27 % of 49 patients with UTUC had positive voided urine cytology, and 33 % of 40 patients had positive split urine cytology. In addition, 40 % of 10 patients had a positive endoscopic biopsy. However, 83 % of 48 patients with UTUC had positive results from FDG-PET/CT examination. The positive predictive value of FDG-PET/CT was 95 %. There were no correlations between sensitivity and tumor stage or tumor grade. Sensitivity of FDG-PET/CT for patients with and without diabetes mellitus was 60 and 89 %, respectively.

CONCLUSIONS

These preliminary results from a small number of patients revealed that FDG-PET/CT enabled effective detection of UTUC.

The oncologic impact of a delay between diagnosis and radical nephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas: results from a large collaborative database

OBJECTIVES

According to the current upper urinary tract urothelial carcinomas (UTUC) guidelines, ureteroscopic evaluation (URS) is recommended to improve diagnostic accuracy and obtain a grade (by biopsy or cytology). However, URS may delay radical surgery [e.g., nephroureterectomy (RNU)]. The objective of this study was to evaluate the influence of URS implementation before RNU on patient survival.

METHODS

A French multicentre retrospective study including 512 patients with nonmetastatic UTUC was conducted between 1995 and 2011. Achievement of ureteroscopy (URS), treatment time (time between imaging diagnosis and RNU), tumour location, pT-pN stage, grade, lymphovascular invasion (LVI) and the presence of invaded surgical margins (R+) were evaluated as prognostic factors for survival using univariate and multivariate Cox regression analyses. Cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were calculated using the Kaplan-Meier method.

RESULTS

A total of 170 patients underwent ureteroscopy prior to RNU (URS+ group), and 342 did not undergo URS (URS-). The median treatment time was significantly longer in the URS+ group (79.5 vs. 44.5 days, p = 0.04). Ureteroscopic evaluation was correlated with ureteral location and lower stage and tumour grade (p = 0.022, 0.005, 0.03, respectively). Tumour stage, LVI+ and R+ status were independently associated with CSS (p = 0.024, 0.049 and 0.006, respectively). The 5-year CSS, RFS and MFS did not differ between the two groups (p = 0.23, 0.89 and 0.35, respectively). These results were confirmed for muscle-invasive (MI) UTUC (p = 0.21, 0.44 and 0.67 for CSS, RFS and MFS, respectively).

CONCLUSIONS

Despite the increased time to radical surgery, diagnostic ureteroscopy can be systematically performed for the appraisal of UTUC to refine the therapeutic strategy without significantly affecting oncological outcomes, even for MI lesions.