Investigating upper urinary tract urothelial carcinomas: a single-centre 10-year experience

Harveer S. Dev,Nimish Shah,Stephanie Poo,Oliver Wiseman,Samih Al-Hayek,James Armitage

doi:10.1007/s00345-016-1820-8

Abstract

ObjectivesEvidence of the accuracy of predictive tests in confirming the presence and grade of upper urinary tract urothelial carcinomas (UUTUC) is limited. We present the largest series evaluating the diagnostic value of pre- and intra-operative parameters in the detection of UUTUC.Materials and methodsWe retrospectively analysed records of patients who underwent diagnostic ureteroscopy between 2005 and 2014 for suspected UUTUC. Pre-operative workup included voided urine cytology and CT imaging. Intra-operative assessments involved ureteroscopy to directly visualise suspicious lesions, and where possible selective cytology and biopsy. Primary outcomes were the visualisation of UUTUC and histopathological confirmation of tumour.ResultsHundred out of 160 (63 %) patients presenting with suspected upper tract malignancy had UUTUC. Voided and selective urine cytology and CT individually predicted UUTUC with a sensitivity/specificity of 63/67, 76/73, and 95/26 %, respectively. Forty out of 48 (83 %) patients who had abnormal CT and abnormal voided urine cytology had UUTUC, while 100 % of those with normal CT and normal voided cytology (investigated for ongoing symptoms) were normal. Comparing endoscopic biopsy to nephroureterectomy specimen grade, 19 (46 %), 18 (44 %), and 4 (10 %) were identical, upgraded, and downgraded, respectively.ConclusionPre-operative investigations can predict UUTUCs. When these investigations were normal, the risk of UUTUC is negligible. In selective patients with abnormal investigations, ureteroscopy should be performed to confirm and predict the grade of UUTUC, in order to guide future management. Selective cytology is unlikely to significantly contribute to the diagnostic workup of UUTUC.

Highlights

Upper urinary tract urothelial carcinoma (UUTUC) is a rare malignancy, accounting for 5 % of all urothelial cancers [11]
Positive cytology was used when a high proportion of cells carried a high index of suspicion for malignant UUTUC, possessing exceedingly abnormal morphology
We support the strategy whereby voided urine cytology and CT are useful as screening tools to identify at-risk patients

Summary

Introduction

Upper urinary tract urothelial carcinoma (UUTUC) is a rare malignancy, accounting for 5 % of all urothelial cancers [11]. Radical nephroureterectomy (RNU) with excision of a bladder cuff remains the gold standard treatment for UUTUC, regardless of the location of the tumour in the upper urinary tract [9]; improvements in endoscopic techniques have led to increasing number of patients being managed endoscopically. World J Urol (2017) 35:131–138 multidetector computed tomography urography (MDCTU or CT) [4]. This is in addition to ureteroscopic findings, which have shown to be important in identifying and predicting the progression of UUTUC [2]. Diagnosis is crucial to tailor individualised management plans and improve outcomes, and delays between diagnosis and surgery have shown to have negative implications on disease recurrence and cancer-specific mortality [8]

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