Photodynamic diagnostic ureterorenoscopy with orally administered 5-aminolaevulinic acid as photosensitiser: how I do it

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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).

Photodynamic Diagnosis with Oral 5-Aminolevulinic Acid for Upper Urinary Tract Carcinoma: A Prospective Clinical Trial

Background and Purpose: In this study, we evaluated the effectiveness and safety of photodynamic diagnosis (PDD) of upper urinary tract carcinoma (UTUC) using oral 5-aminolevulinic acid (5-ALA). Materials and Methods: Consecutive adult patients with suspected UTUC based on imaging and urine cytology findings were prospectively enrolled from May 2018 to January 2019. 5-ALA (20 mg/kg) was orally administered 2 to 3 hours before diagnostic ureteroscopy (URS). Sixty-three biopsy samples were collected from 20 eligible patients using white light (WL) and PDD-URS. The primary endpoint was sensitivity, and the secondary endpoints were specificity, positive predictive value (PPV) and negative predictive value (NPV), diagnostic accuracy, and safety. Results: The sensitivity of photodynamic URS was significantly higher than that of WL-URS (93.8% vs 62.5%, p = 0.0025). Although the specificity and PPV were not different between the two procedures, PDD-URS showed a significantly higher NPV (92.3% vs 69.2%, p = 0.027) and accuracy (0.86 vs 0.75, p = 0.0297) than WL-URS. With respect to safety, no grade ≥3 adverse events related to 5-ALA administration occurred in any patients. Conclusion: We found that PDD-URS with oral 5-ALA is a safe and superior diagnostic tool for detection of UTUC compared with conventional WL-URS.

Which flexible ureteroscope is the best for upper tract urothelial carcinoma treatment?

PURPOSE

To present attributes of currently available flexible ureteroscopes to define the best flexible ureteroscope for upper tract urothelial carcinoma (UTUC) treatment.

MATERIALS AND METHODS

Scopus and Medline databases were searched for articles relating to performance of flexible ureteroscopes. A consensus for final inclusion of articles judged to be relevant for UTUC treatment was reached between the authors. Instrument characteristics were extracted from manufacturers' product brochures.

RESULTS

Smaller cross-sectional size of instruments is associated with increased probability for successful primary access to the upper urinary tract. The smallest flexible ureteroscopes are fiberoptic scopes. Smaller ureteroscopes also allow comparatively increased irrigation flow at constant intrarenal pressure. Digital flexible ureteroscopes achieve superior image quality compared to their fiberoptic counterparts, at the price of lower end-deflection ability. Image enhancement technologies such as narrow-band imaging (NBI), photodynamic diagnosis (PDD) and Image 1-S (formerly SPIES) are based on subjective image interpretation by the operator. NBI and PDD significantly increase tumor detection rate. The highest subjective image quality score of the Image 1-S technology is reached by the "Clara + Chroma" mode. Single-use ureteroscopes offer potential advantages over reusable scopes, including sterility, absence of contamination, immediate availability and exemption of previous instrument wear.

CONCLUSIONS

Miniaturization, digital image caption and image enhancement technologies seem to be the major determinants defining the best flexible ureteroscope for UTUC treatment. The impact of further factors, such as distal tip design, torque, working channel position, risk of contamination, as well as upcoming technological innovations should be evaluated in randomized controlled trials.

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

Objective

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

Materials and methods

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

Results

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

Conclusion

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

Changes in oncological outcomes after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma treated in the last two decades: a retrospective analysis based on a multicenter collaborative study

OBJECTIVE

We investigated chronological changes in the outcomes of patients with upper urinary tract urothelial carcinoma treated in the past two decades, during which there was an important change in treatment paradigm.

METHODS

A retrospective review was conducted of 1180 urinary tract urothelial carcinoma patients who underwent radical nephroureterectomy in multicenter collaborative institutions between 1996 and 2015. The patients were divided into four groups according to the year when radical nephroureterectomy was performed, as follows: 1996-2000 (period 1; P1), 2001-05 (P2), 2006-10 (P3) and 2011-15 (P4). Variables including tumor grade, T and N categories, administration of perioperative chemotherapy and treatment outcomes were compared among the four groups.

RESULTS

There were 146 (12%), 312 (27%), 459 (39%) and 263 (22%) patients in the P1, P2, P3 and P4 groups, respectively. The proportion of patients harboring pT2/3 and Grade 3 tumors increased gradually from 42% (P1) to 58% (P4) and from 49% (P1) to 65% (P4), respectively. The 5-year disease-free survival rates were 74%, 74%, 73% and 75%, and the 5-year overall survival rates were 74%, 65%, 67% and 72% for the P1, P2, P3, and P4 groups, respectively. Multivariate analysis with adjustment for possible confounding factors revealed no significant differences in disease-specific survival, overall survival or intravesical recurrence-free survival among the four groups.

CONCLUSIONS

Despite advances in diagnostic instruments, surgery and systemic chemotherapy, the clinical outcome of urinary tract urothelial carcinoma after radical surgery has not significantly improved over the last two decades, and further research is therefore required.