Fluorescence Confocal Microscopy in Urological Malignancies: Current Applications and Future Perspectives

Fluorescence confocal microscopy (FCM) represents a novel diagnostic technique able to provide real-time histological images from non-fixed specimens. As a consequence of its recent developments, FCM is gaining growing popularity in urological practice. Nevertheless, evidence is still sparse, and, at the moment, its applications are heterogeneous. We performed a narrative review of the current literature on this topic. Papers were selected from the Pubmed, Embase, and Medline archives. We focused on FCM applications in prostate cancer (PCa), urothelial carcinoma (UC), and renal cell carcinoma (RCC). Articles investigating both office and intraoperative settings were included. The review of the literature showed that FCM displays promising accuracy as compared to conventional histopathology. These results represent significant steps along the path of FCM's formal validation as an innovative ready-to-use diagnostic support in urological practice. Instant access to a reliable histological evaluation may indeed significantly influence physicians' decision-making process. In this regard, FCM addresses this still unmet clinical need and introduces intriguing perspectives into future diagnostic pathways. Further studies are required to thoroughly assess the whole potential of this technique.

Prognostic significance of pre-treatment albumin-bilirubin grade in metastatic urothelial carcinoma receiving pembrolizumab

BACKGROUND

Pre-treatment albumin-bilirubin grade is a useful biomarker for predicting prognosis in patients receiving immune checkpoint inhibitors for advanced malignancies. We evaluated the prognostic impact of pre-treatment albumin-bilirubin grade in patients receiving pembrolizumab for metastatic urothelial carcinoma.

METHODS

In this multicenter retrospective study, we calculated pre-treatment albumin-bilirubin scores of 96 patients who received pembrolizumab for metastatic urothelial carcinoma between January 2018 and March 2022. Patients were classified according to albumin-bilirubin grade. Progression-free survival and cancer-specific survival were compared between the groups. To evaluate the prognostic impact of pre-treatment albumin-bilirubin grade, we also performed Cox proportional regression analyses for progression-free survival and cancer-specific survival.

RESULTS

The median pre-treatment albumin bilirubin score was -2.52 (quartile: -2.76 to -2.10), and albumin-bilirubin grade was grade 1 in 37 patients (39%), grade 2a in 30 patients (31%), 2b in 22 patients (23%) and grade 3 in 7 patients (7%). The median progression-free survival and cancer-specific survival were 2 and 7 months, respectively. Progression-free survival and cancer-specific survival were significantly different between the albumin-bilirubin grade groups (P < 0.01 and P < 0.01, respectively) and prognosis became poorer as albumin-bilirubin grade increased. High albumin-bilirubin grade was shown in multivariable Cox proportional analyses to be independently associated with both poor progression-free survival and poor cancer-specific survival.

CONCLUSIONS

High pre-treatment albumin-bilirubin grade could be a significant independent predictor of poor prognosis in patients receiving pembrolizumab for advanced urothelial carcinoma.

Intravesical Recurrence after Radical Nephroureterectomy in Patients with Upper Tract Urothelial Carcinoma Is Associated with Flexible Diagnostic Ureteroscopy, but Not with Rigid Diagnostic Ureteroscopy

(1) Background: We assessed the impact of diagnostic ureteroscopy (URS) on intravesical recurrence (IVR) following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma according to the type of URS. (2) Methods: Data on 491 consecutive patients who underwent RNU at two institutions between 2016 and 2019 were retrospectively reviewed. The study population was classified according to the type of URS performed before RNU as follows: non-URS, rigid URS, and flexible URS. The study outcome was IVR occurring within 1 year of RNU. Univariable and multivariable Cox proportional hazards models were used to estimate the risk of IVR. (3) Results: Altogether, 396 patients were included for analysis. Rigid and flexible URS were performed in 178 (45%) and 111 (28%) patients, respectively, while 107 (27%) patients did not undergo URS. IVR was identified in 99 (25%) patients. Multivariable Cox regression analysis revealed that the flexible URS group was significantly associated with increased IVR, compared to the non-URS group (HR = 1.807, p = 0.0416). No significant difference in IVR was observed between the non-URS and rigid URS groups (HR = 1.301, p = 0.3388). (4) Conclusions: In patients with UTUC undergoing RNU, rigid URS may not increase the risk of IVR, whereas flexible URS appears to be associated with a higher risk of IVR.

A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond

Purpose

The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC.

Methods

We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed.

Results

We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09–1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96–1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19–2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50–4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery.

Conclusions

A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.

Case of inverted papillary urothelial carcinoma in the ureter

Introduction

Urothelial neoplasms with a varus growth pattern are rare, and few urologists have encountered inverted urothelial carcinoma of the ureter.

Case presentation

An 82‐year‐old man was referred to our hospital for investigation of gross hematuria. Magnetic resonance imaging revealed nodules measuring 1–2 mm in diameter in the left upper ureter with slight reduction in signal intensity on diffusion‐weighted imaging. Ureteroscopy showed a pedunculated smooth tumor that had the appearance of an inverted papilloma rather than the papillary shape typical of urothelial carcinoma. The tumor was biopsied and histopathological examination revealed a noninvasive, low‐grade urothelial carcinoma with inverted multiple layers. Laparoscopic radical nephroureterectomy was subsequently performed, and a pedunculated tumor measuring 20 mm in diameter was found in the left upper ureter. The histopathological diagnosis was inverted papillary urothelial carcinoma, low‐grade, pTa, pN0.

Conclusion

This report provides the first clinical description of inverted papillary urothelial carcinoma of the ureter.

The Impact of Upper Tract Urothelial Carcinoma Diagnostic Modality on Intravesical Recurrence after Radical Nephroureterectomy: A Single Institution Series and Updated Meta-Analysis

PURPOSE

Diagnostic ureteroscopic biopsy for upper tract urothelial carcinoma (UTUC) has been hypothesized to increase intravesical recurrence of urothelial carcinoma after radical nephroureterectomy (RNU). Moreover, the impact of ureteroscopy without biopsy or percutaneous biopsy on intravesical recurrence remains unknown. Herein, we compared post-RNU intravesical recurrences across UTUC diagnostic modalities.

MATERIALS AND METHODS

Patients undergoing RNU at our institution between 1995 and 2019 were categorized by UTUC diagnostic modality: 1) no ureteroscopy or percutaneous biopsy; 2) percutaneous biopsy; 3) ureteroscopy without biopsy; 4) ureteroscopic biopsy. Intravesical recurrences were compared using Kaplan-Meier analyses and Cox-proportional hazard models. Results of group 4 vs 1 were pooled with the literature using a fixed effects meta-analysis.

RESULTS

In a cohort of 834 RNU patients, 210 (25.2%) had undergone no ureteroscopy, 57 (6.6%) percutaneous biopsy, 125 (15.0%) ureteroscopy without biopsy, and 442 (53.0%) ureteroscopic biopsy. Two-year intravesical recurrence rates were 15.0%, 12.7%, 18.4%, and 21.9% for groups 1 through 4, respectively (p=0.09). Multivariable analysis found that group 4 had increased intravesical recurrences (HR 1.40, p=0.04) relative to group 1 while group 2 (HR 1.07, p=0.87) and group 3 (HR 1.15, p=0.54) did not. Group 4 remained associated with intravesical recurrence on subset analyses accounting for post-RNU surveillance cystoscopy frequency. On meta-analysis including 11 other series, ureteroscopic biopsy was associated with intravesical recurrence (HR 1.47, p <0.01).

CONCLUSIONS

Ureteroscopic biopsy before RNU, but not percutaneous biopsy or ureteroscopy without biopsy, was associated with increased intravesical recurrence. Clinical trials of intravesical chemotherapy after ureteroscopic biopsy are warranted to reduce intravesical recurrences.

Expression Analysis of Same-Patient Metachronous and Synchronous Upper Tract and Bladder Urothelial Carcinoma

PURPOSE

We compared upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BUC) in same-patient metachronous UTUC and synchronous UTUC and BUC using next-generation sequencing.

MATERIALS AND METHODS

Consecutive untreated same-patient samples of UTUC and BUC were macrodissected from unstained formalin-fixed, paraffin-embedded slides after quality control. Samples were divided into 4 groups: 1) UTUC-metachronous BUC, 2) BUC-metachronous UTUC, 3) synchronous UTUC-BUC, 4) UTUC without BUC. Exclusions were inadequate clinical data or histological tumor purity <30%. Whole transcriptome RNA sequencing was performed. After quality assessment, gene expression clusters using unsupervised hierarchical consensus clustering and correlation with pertinent clinicopathologic variables, a prior RNASeq data set and other published data were performed.

RESULTS

RNAseq was performed on 95 samples (UTUC=61, BUC=34) from 40 untreated patients. Unsupervised consensus clustering segregated the tumors into 2 clusters that were enriched with BASE47 basal-like or luminal-like gene expression. Almost two-thirds (61.9%) of Group 2 tumors were basal-like, while the majority of Groups 1, 3, 4 (80.6%, 70.0% and 69.6%, respectively) were luminal-like (p=0.017). Further analyses revealed that the differences in basal-like and luminal-like gene expression were associated with differential fibroblast and immune cell gene expression signatures. In all, 87.5% of metachronous tumors maintained subtype membership.

CONCLUSIONS

Gene expression analysis of same-patient metachronous UTUC-BUC suggests that the majority of mUTUC developing after BUC appear more basal-like, while synchronous and initial UTUC tumors appear luminal-like. Metachronous tumors largely maintain molecular subtype membership of the initial tumor regardless of chronologic development or anatomical origin.

Risk Factors for Intravesical Recurrence after Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Cancer (ROBUUST Collaboration)

PURPOSE

Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort.

MATERIALS AND METHODS

We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence.

RESULTS

A total of 485 (396 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031).

CONCLUSIONS

IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.

CT Findings of Upper Urinary Tract Lesions in IgG4-Related Disease: Comparison With Urothelial Carcinoma

OBJECTIVE. IgG4-related disease is characterized by extensive infiltration of IgG4-positive plasma cells and fibrosis in various organs. The objective of this study is to investigate CT findings of IgG4-related lesions involving the upper urinary tract and compare them with those of urothelial carcinomas. MATERIALS AND METHODS. This study reviewed pretreatment CT images of 13 consecutive patients with IgG4-related disease with upper urinary tract lesions and 80 consecutive patients with urothelial carcinomas. The findings assessed were laterality, location, growth pattern, margins, internal structure, presence of calcification and lipid component, enhancement pattern, and extraurinary findings. RESULTS. Bilaterality (p < 0.0001), an extramural growth pattern (p < 0.0001), a greater number of affected segments (p = 0.04), and a gradual dynamic enhancement pattern (p < 0.001) were significantly more frequent in patients with IgG4-related disease. With regard to extraurinary findings, paraaortic fat stranding (p = 0.03), presacral fat stranding (p < 0.001), fat stranding of the pelvic walls (p < 0.001), and aortic involvement (p < 0.001) were seen more frequently in patients with IgG4-related disease; on the other hand, there was no statistically significant difference in terms of frequency of pancreatic involvement. Hydronephrosis and renal involvement were seen more frequently in patients with urothelial carcinoma, although the difference was not statistically significant. CONCLUSION. CT findings suggestive of IgG4-related upper urinary tract lesions in comparison with urothelial carcinoma are bilateral and have a longer urinary tract involvement and exhibit an extramural growth pattern, ill-defined margins, a gradual enhancement pattern, aortic involvement, and fat stranding in the paraaortic, presacral, or pelvic wall areas.

Optimal Management of Upper Tract Urothelial Carcinoma: Current Perspectives

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) is a relatively uncommon urologic malignancy for which there has not been significant improvement in survival over the past few decades, highlighting the need for optimal multi-modality management.

METHODS

A non-systematic review of the latest literature was performed to include relevant articles up to June 2019. It summarizes the epidemiologic risk factors associated with UTUC, including smoking, carcinogenic aromatic amines, arsenic, aristolochic acid, and Lynch syndrome. Molecular pathways underlying UTUC and potential druggable targets are outlined.

RESULTS

Surgical management for UTUC includes kidney-sparing surgery (KSS) for low-risk disease and radical nephroureterectomy (RNU) for high-risk disease. Endoscopic management of UTUC may include ureteroscopic or percutaneous resection. Topical instillation therapy post-KSS aims to reduce recurrence, progression and to treat carcinoma-in-situ; this may be achieved retrogradely (via ureteric catheterization), antegradely (via percutaneous nephrostomy) or via reflux through double-J stent. RNU, which may be performed via open, laparoscopic or robot-assisted approaches, is the gold standard treatment for high-risk UTUC. The distal cuff may be dealt with extravesical, transvesical or endoscopic techniques. Peri-operative chemotherapy and immunotherapy are increasingly utilized; level 1 evidence exists for adjuvant chemotherapy, but neoadjuvant chemotherapy is favored as kidney function is better prior to RNU. Immunotherapy is primarily reserved for metastatic UTUC but is currently being investigated in the perioperative setting.

CONCLUSION

The optimal management of UTUC includes a firm understanding of the epidemiological factors and molecular pathways. Surgical management includes KSS for low-risk disease and RNU for high-risk disease. Peri-operative immunotherapy and chemotherapy may be considered as evidence mounts.

Down-Grading of Ipsilateral Hydronephrosis by Neoadjuvant Chemotherapy Correlates with Favorable Oncological Outcomes in Patients Undergoing Radical Nephroureterectomy for Ureteral Carcinoma

Few studies have analyzed the details of neoadjuvant chemotherapy (NAC)-induced changes in patients with upper tract urothelial carcinoma. This study aimed to describe the impact of down-grading ipsilateral hydronephrosis by NAC for ureteral carcinoma. An observational study was conducted in 32 patients with cT1-3N0M0 ureteral carcinoma treated with NAC and radical nephroureterectomy. Hydronephrosis was classified into five grades based on computed tomography findings. We focused on the differences between the baseline and post-NAC status of ipsilateral hydronephrosis, radiographic tumor response, and blood markers. Down-grading, no change, and up-grading was observed in 10 (31%), 21 (66%), and 1 (3%) patients, respectively. In univariate analysis, locally advanced disease (cT3), severe hydronephrosis (grade 3/4) at baseline, no change/up-grading of hydronephrosis after NAC, and pathological lymphovascular involvement were identified as potential prognostic factors of progression-free and cancer-specific survival after radical nephroureterectomy. Locally advanced disease (cT3) at baseline and no change/up-grading of hydronephrosis by NAC were independently associated with poor progression-free survival. Notably, none of the patients with NAC-induced down-grading of hydronephrosis died of ureteral carcinoma during the follow-up. We reported the prognostic impact of down-grading of ipsilateral hydronephrosis, which could serve as a useful aid or clinical marker for decision-making.

Systematic Review: An Update on the Spectrum of Urological Malignancies in Lynch Syndrome

Background:

Lynch syndrome is an autosomal dominant disorder that predisposes individuals affected to certain malignancies. Colon and endometrial cancers are the malignancies most highly associated with Lynch syndrome. However, growing body of evidence links Lynch syndrome to urological cancers.

Objective:

This review aims to clarify the type of urological malignancies that fall under the Lynch-associated cancer spectrum.

Methods:

Using PRISMA guidelines, a systematic search between January 1990 to February 2018, was conducted using the MEDLINE database with the application of the following MESH terms: colorectal neoplasms, hereditary nonpolyposis; DNA mismatch repair; urologic neoplasms; kidney pelvis; ureteral neoplasms; urinary bladder; carcinoma, transitional cell; prostatic neoplasms; testicular neoplasms.

Results:

Upper tract urothelial cancers are well established under the Lynch spectrum. Increasing evidence supports its association with prostate cancer. However, there is, inconclusive and limited evidence for an association with bladder and testicular cancer.

Conclusions:

The evidence underpinning certain urological malignancies associated with Lynch syndrome has expanded in recent years. Our review may assist in providing a summary of the current standing in literature. However, we recommend further investigations to better clarify associations, particularly with prostate, bladder and testicular cancer.

Risk factors, follow-up, and treatment of urethral recurrence following radical cystectomy and urinary diversion for bladder cancer: a meta-analysis of 9498 patients

Purpose

Patients frequently undergo radical cystectomy and urinary diversion for treatment of bladder cancer. However, they remain at risk of urethral recurrence (UR). Studies have determined various risk factors leading to urethral recurrence. However, no publications have weighed the predictive values of these factors.

Materials and Methods

Studies published between 1971 and 2016 were retrieved from PubMed, EMBASE and MEDLINE. We used STATA software (Version 12.0) to estimate the pooled risk ratio.

Results

Twenty-five publications with 9498 patients were included. Overall, male patients, especially those with concomitant carcinoma in situ, superficial or intravesical bladder cancer, non-orthotopic diversion, prostatic involvement, bladder neck involvement, positive urethral margins or multifocal bladder cancer were at higher risk of urethral recurrence. The overall risks of recurrence, reported as risk ratios, varied widely. Among all 25 studies, 118 (60.2%) cases in 9 studies were diagnosed through routine follow-up. Another 82 (40.8%) patients in 11 studies first reported symptomatic abnormalities. Prognoses were worse for patients with symptomatic recurrence. Urethral cytology was the most common diagnostic method. Treatment after UR was reported for 272 cases in 14 publications, and 190 patients underwent urethrectomy and 52 underwent urethra-sparing treatments. Outcomes after UR were described in 12 studies reporting 180 cases, and 41 patients were alive through the end of follow-up and 65 patients died of bladder cancer.

Conclusions

UR following radical cystectomy for bladder cancer was closely related to risk factors. Precautions, strict follow-up protocols and rational therapies were critical to patients with high risks of urethral recurrences.

Non-transitional cell carcinoma of the upper urinary tract: A case series among 305 cases at a tertiary urology institute

Non-transitional cell carcinomas (non-TCC) of the upper urinary tract as squamous cell carcinoma (SCC), adenocarcinoma, and small cell carcinoma (SmCC) are rare with few case reports in the literature. We retrospectively reviewed our patients who surgically treated for upper tract urothelial carcinoma from 1983 to 2013 for non-TCC pathological cancer characteristics and survival. Among 305 patients, only 5 (1.6%) cases were found: One case of SmCC, another had adenocarcinoma, and 3 SCC cases. None of them had intravesical recurrence and the cancer-specific survival for non-TCC cohort is markedly decreased (log-rank = 0.01) compared to TCC patients.

Concurrent bladder cancer in patients undergoing photodynamic diagnostic ureterorenoscopy: how many lesions do we miss under white light cystoscopy?

INTRODUCTION

There is an ongoing debate on panurothelial changes in the upper and lower urinary tract as multifocal presentation of urothelial cancer is well recognised. Concurrent bladder cancer impacts the outcome of the upper urinary tract urothelial cancer treatment, while its detection still relies on the white light cystoscopy.

MATERIAL AND METHODS

We retrospectively reviewed all patients who underwent photodynamic diagnostic ureterorenoscopy, choosing those who had synchronous bladder biopsies. Each patient received 20 mg/kg body weight of oral 5-Aminolevulinic acid around 3-4 hours before endoscopy. All procedures were performed by a single endourologist experienced in photodynamic diagnosis and flexible ureterorenoscopy.

RESULTS

Between July 2009 and June 2013, 69 patients underwent bladder biopsies at the time of photodynamic diagnostic endoscopic inspection of the upper urinary tract. In total, 43.5% (30/69) patients were found to have bladder lesions, of which 43.3% (13/30) were proven to be carcinoma in situ. White light inspection of the bladder missed bladder cancer in 16 (23.1%) patients, of which 12 were carcinoma in situ. There were 14 bladder cancer lesions missed under white light which were concomitant to the upper urinary tract urothelial cancer. Twelve (17.4%) patients developed minor complications relevant to the photosensitizer.

CONCLUSIONS

The study raises a concern about missing small bladder cancer/carcinoma in situ lesions on the initial diagnosis or in surveillance of the upper urinary tract urothelial cancer. Higher than previously reported, the rate of concomitant bladder cancer may suggest utilisation of photodynamic diagnosis to ensure the cancer free status of the bladder, but this needs to be ratified in a multi-institutional randomised trial.

Metachronous urothelial carcinoma of whole urinary tract in a dialysis-dependent patient: A case report

Numerous studies have reported an association between end-stage renal disease (ESRD) and malignancy. The predominant malignant tumor that occurs in patients with ESRD in Asian countries is urothelial carcinoma (UC). According to recent research, cases of UC in dialysis-dependent patients are associated with higher recurrence rates and more aggressive biological behavior compared with patients without ESRD. The necessity of 1-step total urinary tract exenteration for dialysis-dependent patients with UC is advocated by certain studies. The current study reports a case of metachronous bladder cancer and bilateral upper urinary tract tumor in a dialysis-dependent patient. Three separate surgeries were performed to remove the bladder, and left and right urinary tract, respectively. The question of whether the stepwise strategy or the 1-step surgery should be selected for such special cases remains in debate.

DWI in the Etiologic Diagnosis of Excretory Upper Urinary Tract Lesions: Can It Help in Differentiating Benign From Malignant Tumors? A Retrospective Study of 98 Patients. AJR Am J Roentgenol. 2016;207:106-113. [PMID: 27064313 DOI: 10.2214/ajr.15.15652]

OBJECTIVE

The objective of this study was to evaluate the diagnostic performance of high-field DWI in distinguishing benign from malignant lesions of the upper urinary tract (UUT).

MATERIALS AND METHODS

Ninety-eight patients who underwent 3-T DWI (b = 1000 s/mm(2)) for assessment of a UUT lesion were retrospectively included in the study. Data on the size, location, and mean apparent diffusion coefficient (ADC) value of the lesions were collected and correlated with the final diagnosis. ROC curve analysis was used to determine the best threshold value of the mean ADC for characterization of the lesions.

RESULTS

A total of 66 carcinomas and 33 benign lesions were identified. The mean (± SD) ADC value was statistically significantly lower for the malignant lesions than for the benign lesions (0.984 ± 0.048 vs 1.536 ± 0.067 × 10(-3) mm(2)/s; p = 0.000007). For characterization of malignant lesions, the best cutoff ADC value on the ROC curve was found to be less than or equal to 0.996 10(-3) mm(2)/s. On the basis of this value, the sensitivity and specificity of 3-T DWI for the identification of malignant UUT lesions were 78.3% and 95.5%, respectively, with a positive predictive value of 94.7% and a negative predictive value of 80.8% (p = 0.0001). The thickness of the smallest lesion was 3 mm. The mean ADC value of high-grade tumors was not statistically significantly lower than that of low-grade tumors. The best cutoff value for predicting benignancy was greater than or equal to 1.100 × 10(-3) mm(2)/s with sensitivity of 90.9%, specificity of 82.6%, positive predictive value of 83.3%, and negative predictive value of 90.5%.

CONCLUSION

The ADC measurement is a useful additional parameter in the differentiation of benign from malignant UUT lesions.

Treatment Effects of WST11 Vascular Targeted Photodynamic Therapy for Urothelial Cell Carcinoma in Swine

PURPOSE

Surgical management of upper tract urothelial carcinoma requires kidney and ureter removal, compromising renal function. Nonsurgical alternatives have potentially prohibitive safety concerns. We examined the feasibility and safety of ablation of the ureter and renal pelvis using endoluminal vascular targeted photodynamic therapy in a porcine model. We also report the efficacy of WST11 vascular targeted photodynamic therapy in a murine model.

MATERIALS AND METHODS

After receiving approval we performed a total of 28 endoluminal ablations in the ureters and renal pelvis of 18 swine. Intravenous infusion of WST11 (4 mg/kg) followed by 10-minute laser illumination was done via percutaneous access or a retrograde ureteroscopic approach. Animals were followed clinically with laboratory testing, imaging and histology, which were evaluated at several postablation time points. A murine xenograft was created with the 5637 human urothelial cell carcinoma line to determine sensitivity to this therapy.

RESULTS

At 24 hours 50 mW/cm laser fluence produced superficial necrosis of the ureter. Deeper necrosis penetrating the muscularis propria or adventitia was produced by treatment with 200 mW/cm in the ureter and the renal pelvis. At 4 weeks superficial urothelium had regenerated over the treatment site. No symptomatic obstruction, clinically relevant hydronephrosis or abnormality of laboratory testing was noted up to 4 weeks. Of the mice 80% had no evidence of tumor 19 days after WST11 vascular targeted photodynamic therapy.

CONCLUSIONS

Urothelial cell carcinoma appears to be sensitive to WST11 vascular targeted photodynamic therapy. The depth of WST11 vascular targeted photodynamic therapy treatment effects can be modulated in a dose dependent manner by titrating light intensity. Moreover, when applied to the porcine upper urinary tract, this treatment modality is feasible via antegrade and retrograde access.

Patterns of Lymphatic Metastases in Upper Tract Urothelial Carcinoma and Proposed Dissection Templates

PURPOSE

Information on patterns of lymph node metastases for upper tract urothelial carcinoma is sparse. We investigated patterns of lymph node metastases in upper tract urothelial carcinoma.

MATERIALS AND METHODS

We performed a retrospective multi-institutional study of 73 patients with N+M0 upper tract urothelial carcinoma who underwent template lymphadenectomy during nephroureterectomy. Anatomical locations of tumor, and number of lymph nodes removed and positive lymph nodes were analyzed and descriptive statistics were performed.

RESULTS

On the right side the 20 renal pelvis tumors had lymph node metastases to the hilum in 22.1% of cases, and to paracaval, retrocaval and interaortocaval regions in 44.1%, 10.3% and 20.6%, respectively. The 10 proximal ureter tumors had lymph node metastases to the hilum in 46.2% of cases, and to paracaval and retrocaval regions in 46.2% and 7.7%, respectively. The 2 distal ureter tumors had lymph node metastases equally to the paracaval and pelvic regions. On the left side the 24 renal pelvis tumors had lymph node metastases to the hilum region in 50.0% of cases and to the para-aortic region in 30.0%. The 8 proximal ureter tumors had lymph node metastases to the hilum region in 36.4% of cases and the para-aortic region in 63.6%. The 5 mid ureter tumors had lymph node metastases to the para-aortic, common iliac and internal iliac regions in 40%, 40% and 20% of cases, respectively. The 4 distal ureter tumors had lymph node metastases to the para-aortic, common iliac, external iliac and internal iliac regions in 33.3%, 33.3%, 16.7% and 16.7% of cases, respectively. Interaortocaval involvement from both sides as well as out of field lymph node metastases appeared to occur secondarily. Consolidated templates were constructed based on the available data.

CONCLUSIONS

Upper tract urothelial carcinoma has characteristic patterns of lymph node metastases depending on the side and anatomical location of the primary tumor, including right-to-left migration and involvement of interaortocaval nodes in the setting of proximal disease. Standardized dissection templates should be prospectively evaluated in multicenter trials to assess morbidity and potential clinical benefit.

Benign fibroepithelial polyp of the ureter

Benign tumors of the ureter are rare and most often appear in the form of fibroepithelial polyps [1]. Fibroepithelial polyps represent from 2 to 6% of all benign tumors of the urinary tract [2]. The Authors report on two cases of fibroepithelial polyps of the ureter, which they treated between 1993–2009. One case was presented by acute urinary retention and gross hematuria. In the second case, hematuria and flank pain were observed. The first case was treated with open surgery and partial resection of the ureter, the second was treated endoscopically when the base of the polyp was well identified.

Preoperative risk factors for extraurothelial recurrence in patients with ureteral cancer treated with radical nephroureterectomy

PURPOSE

Recent studies have suggested that lymph node dissection may improve the prognosis in patients with upper tract urothelial carcinoma. Therefore, patients who will benefit from lymph node dissection need to be selected before surgery. Because patients who have extraurothelial recurrence theoretically include those whose prognoses are improved by lymph node dissection, we conducted this study to determine the preoperative predictors of extraurothelial recurrence in patients with ureteral cancer.

MATERIALS AND METHODS

Because it is not appropriate to categorize the preoperative radiologic findings of ureteral cancer and those of renal pelvic cancer using the same classification criteria, we focused on ureteral cancer. We reviewed preoperative factors in 70 patients with ureteral cancer treated with radical nephroureterectomy. Laboratory tests including inflammatory indices, tumor markers and estimated glomerular filtration rate, along with radiologic findings, were evaluated. Multivariate analyses were performed to determine independent factors predicting extraurothelial recurrence in patients with ureteral cancer.

RESULTS

Positive cytology, cT stage 3 or greater, length of ureteral cancer 3 cm or greater and estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 were independent predictors of extraurothelial recurrence on multivariate analysis. When patients were stratified into 3 groups according to the number of risk factors, the 3-year extraurothelial recurrence-free survival rates were 95.2% in the low risk group, 75.8% in the intermediate risk group and 25.1% in the high risk group.

CONCLUSIONS

Positive cytology, cT stage 3 or greater, length of ureteral cancer 3 cm or greater and estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 were preoperative predictive factors of extraurothelial recurrence in patients with ureteral cancer and lymph node dissection may be omitted for low risk patients.

Conservative management of upper tract transitional cell carcinoma

Aim

Our aim was to review the current literature describing the endoscopic management of upper tract transitional cell carcinoma (TCC).

Materials and Methods

Review of published, peer-reviewed articles relating the primary ureteroscopic or percutaneous management of upper tract TCC was performed using the MEDLINE database.

Results

Historically, the gold-standard management for upper tract TCC consists of nephroureterectomy with excision of a bladder cuff. The employment of endoscopic management with these neoplasms was initially instituted in individuals with imperative indications, including bilateral disease, solitary kidney, and/or renal insufficiency. For individuals treated with ureteroscopy, recurrence rates range from 30 to 71% and cancer-specific survival rates from 50 to 93%. Results are dependent primarily on tumor grade and stage. In individuals with low-stage, low-grade tumors treated percutaneously, recurrence rates, and cancer-specific survival rates are 18-33% and 94-100%, respectively. Adjuvant therapy has been employed with thiotepa, mitomycin, and BCG, but none have been able to demonstrate a statistically significant difference in recurrence or cancer-specific survival rates.

Conclusions

Endoscopic management is a safe and effective treatment alternative to nephroureterectomy in the management of upper tract TCC. Survival outcomes are comparable, but renal preservation therapy offers the advantage of reduced morbidity, complications, and the potential for better quality of life. Recurrence and disease progression are not uncommon and underscore the need for strict tumor surveillance.

Robotic nephroureterectomy with partial duodenectomy for invasive ureteral tumor

Robotic surgery is gaining acceptance in the management of diverse urological disorders. Any minimally invasive procedure carries a risk of open conversion either for complications or unexpected intraoperative findings, but the additional dexterity of robotic instrumentation may allow even complex situations to be managed laparoscopically. We report the case of an upper tract transitional cell carcinoma discovered at the time of robotic nephroureterectomy to be invading the duodenum that was successfully excised robotically.

Hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device

Various laparoscopic nephroureterectomy techniques for urothelial carcinoma of the upper urinary tract have been developed to minimize postoperative discomfort and the necessity for a lengthy convalescence. We performed hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device in 3 male patients with urothelial carcinoma of the distal ureter. Average operative time and estimated blood loss were 251 min (range 235 to 280) and 250 mL (range 200 to 300), respectively. Complication did not occur and conversion to open surgery was not necessary in all cases. Postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days (range 2 to 4). None of the patients had a positive margin on the final pathologic specimen. At the average follow-up of 8.1 months, no regional recurrence, port-site metastasis, bladder recurrence, or distant metastasis were noted in any patient. We described our initial experience with the described technique, which obviates the need for midprocedural patient repositioning.