Ureteroscopic Biopsy Research Articles

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

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

Carcinoma in situ is significantly underdetected by prenephroureterectomy ureteroscopy in the management of upper tract urothelial cancers.

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Feasibility of obtaining biomarker profiles from endoscopic biopsy specimens in upper tract urothelial carcinoma: Preliminary results

ObjectiveTo prospectively evaluate the feasibility of obtaining a reliable histochemical assessment of cell cycle biomarkers from endoscopic biopsy specimens of patients with upper tract urothelial cancer. MethodsOverall, 17 patients were identified who had an available biopsy as well as those who underwent subsequent radical nephroureterectomy (RNU) or segmental ureterectomy (SU) for clinically localized high-grade upper tract urothelial cancer of the renal pelvis or ureter. Of those 17 patients, 15 (88%) had sufficient tissue to undergo immunohistochemical staining. Biopsies were obtained using various endoscopic techniques. Tumor characteristics were recorded and prospectively evaluated for immunohistochemical expression of 5 biomarkers: p21, p27, p53, cyclin E, and Ki67/pRb. Unfavorable prognostic score (PS) was defined as>2 altered markers. ResultsThe median age of the patients was 68 years (range: 53–82y) with 87% being males. Of the 15 specimens, 9 (60%) tumors were organ confined (T≤2 and N0), and all were high grade. Of the 15 patients, 4 (27%), 7 (46.6%), 3 (20%), and 1 (6.7%) individuals had 1, 2, 3, and 5 markers altered on biopsy marker profiling, respectively, with Ki67 being the most frequent alteration (13/15; 87.7%).An overall concordance rate of 60% (9/15) was seen between biopsy and RNU/SU PS. Those patients with favorable biopsy biomarker PS were less likely to display adverse pathological features, with organ-confined disease in 7/11 (63.6%) patients and 9/11 (81.8%) being free of carcinoma in situ in the final specimen. Additionally, 10/11 (91%) had no evidence of necrosis and 7/11 (64%) had no evidence of lymphovascular invasion on final pathologic evaluation. ConclusionsPreliminary results suggest that obtaining interpretable biomarker profile of ureteroscopic biopsy specimens is feasible. Tumor heterogeneity and limited biopsy material may account for the discordance between biopsy and RNU/SU specimens. Meaningful biopsy biomarker profiling could serve as a powerful tool for individualizing treatment regimens and augmenting current predictive variables. Further studies are needed to evaluate clinical applicability.

C130: Correlation between ureteroscopic biopsy and pathology reports after nephroureterectomy for patients with upper urinary tract tumors

C130: Correlation between ureteroscopic biopsy and pathology reports after nephroureterectomy for patients with upper urinary tract tumors

Primary Ewing sarcoma/primitive neuroectodermal tumor of the renal pelvis: a case report

Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET) is a childhood malignancy, typically occurring in the bone and rarely in any other part of the body. We herein present a case of ES/PNET of the renal pelvis. A 37-year-old male patient presented with a chief complaint of pain in the left flank and gross hematuria. The tumor had caused moderate hydronephrosis, and ureteroscopic biopsy findings were highly suspicious of sarcoma. Subsequently, radical nephroureterectomy was performed. On the basis of the pathological and cytogenetic findings, a final diagnosis of primary ES/PNET of left renal pelvis was made. Adjuvant chemotherapy with adriamycin and ifosfamide was initiated as ES/PNET often exhibits aggressive biological behavior. The patient was disease-free at his last regular follow-up visit 18 months after the surgery. To our knowledge, this is the first reported case of primary ES/PNET of the renal pelvis.

Diagnosis of upper tract urothelial carcinoma—a comparative study of urinary cytology and surgical biopsy

Upper tract urothelial carcinoma (UTUC) is defined as urothelial carcinoma (UC) arising in the renal pelvis and ureter. Upper tract (UT) cytology and biopsy evaluation can be technically challenging. The aim of the study is to evaluate the diagnostic modality and sensitivity of urine cytology and ureteroscopic biopsy for the diagnosis of UTUC. All patients with UTUC who underwent radical nephroureterectomy or ureterectomy with preoperative cytology and/or biopsy from January 1, 2000 to September 30, 2011 at our institution were included in this study. The sensitivity of each diagnostic modality was calculated with respect to tumor grade, stage, and size. A total of 143 cytology specimens and 54 biopsies from 65 patients were evaluated. For low-grade UTUC, the sensitivities for biopsy, lower tract cytology, and UT cytology were 68.4%, 27.3%, and 37.5%, respectively. These numbers were 82.9%, 40.7%, and 80.6% for high-grade UTUC. By combining the UT cytology and biopsy, the diagnostic sensitivities were increased to 87.5% for low-grade UTUC and 100% for high-grade UTUC. The consistency of tumor grade between biopsy and surgical specimen were 63.2% for low-grade UTUC and 68.6% for high-grade UTUC. Both UT cytology and biopsy showed higher sensitivity in detecting high-grade UTUC versus low-grade UTUC. The sensitivities of UT cytology and ureteroscopic biopsy in detecting high-grade UTUC were comparable. The sensitivity was greatly improved when these diagnostic modalities were combined. As expected, the selective UT cytology evaluation had superior sensitivity in detecting UTUC than did the lower tract cytology sampling.

MP77-10 PROGNOSTIC RELEVANCE OF PLATELET COUNT KINETICS IN PATIENTS WITH UPPER TRACT UROTHELIAL CARCINOMA AFTER RADICAL NEPHROURETERECTOMY

7/11 (63.6%) patients and 9/11 (81.8%) free of CIS in the final specimen. Additionally, 10/11 (91%) had no evidence of necrosis and 7/11 (64%) had no evidence of lymphovascular invasion on final pathological evaluation. CONCLUSIONS: Preliminary results suggest that obtaining interpretable biomarker profile of ureteroscopic biopsy specimens is feasible. Tumor heterogeneity and limited biopsy material may account for the discordance between biopsy and RNU/SU specimens. Meaningful biopsy biomarker profiling could serve as a powerful tool for individualizing treatment regimens and augmenting current predictive variables. Further studies are needed to evaluate clinical applicability. Figure 1: Correlation of Individual Markers between Biopsy and RNU/SU

MP77-09 FEASIBILITY OF OBTAINING BIOMARKER PROFILES FROM ENDOSCOPIC BIOPSY SPECIMENS IN UPPER TRACT UROTHELIAL CARCINOMA: PRELIMINARY RESULTS

Objective: To prospectively evaluate the feasibility of obtaining a reliable histochemical assessment of cell cycle biomarkers from endoscopic biopsy specimens of patients with upper tract urothelial cancer. Methods: Overall, 17 patients were identified who had an available biopsy as well as those who underwent subsequent radical nephroureterectomy (RNU) or segmental ureterectomy (SU) for clinically localized high-grade upper tract urothelial cancer of the renal pelvis or ureter. Of those 17 patients, 15 (88%) had sufficient tissue to undergo immunohistochemical staining. Biopsies were obtained using various endoscopic techniques. Tumor characteristics were recorded and prospectively evaluated for immunohistochemical expression of 5 biomarkers: p21, p27, p53, cyclin E, and Ki67/pRb. Unfavorable prognostic score (PS) was defined as 42 altered markers. Results: The median age of the patients was 68 years (range: 53–82 y) with 87% being males. Of the 15 specimens, 9 (60%) tumors were organ confined (T r 2 and N0), and all were high grade. Of the 15 patients, 4 (27%), 7 (46.6%), 3 (20%), and 1 (6.7%) individuals had 1, 2, 3, and 5 markers altered on biopsy marker profiling, respectively, with Ki67 being the most frequent alteration (13/15; 87.7%). An overall concordance rate of 60% (9/15) was seen between biopsy and RNU/SU PS. Those patients with favorable biopsy biomarker PS were less likely to display adverse pathological features, with organ-confined disease in 7/11 (63.6%) patients and 9/11 (81.8%) being free of carcinoma in situ in the final specimen. Additionally, 10/11 (91%) had no evidence of necrosis and 7/11 (64%) had no evidence of lymphovascular invasion on final pathologic evaluation. Conclusions: Preliminary results suggest that obtaining interpretable biomarker profile of ureteroscopic biopsy specimens is feasible. Tumor heterogeneity and limited biopsy material may account for the discordance between biopsy and RNU/SU specimens. Meaningful biopsy biomarker profiling could serve as a powerful tool for individualizing treatment regimens and augmenting current predictive variables. Further studies are needed to evaluate clinical applicability. r 2014 Elsevier Inc. All rights reserved.

Metastasis of renal cell carcinoma to the contralateral ureter

We herein report a rare case of renal cell carcinoma (RCC) that metastasized to the contralateral ureter. A 55-year-old man with a past history of right radical nephrectomy due to G3 pT1b clear cell RCC one year earlier presented to our department with a complaint of gross hematuria. On computed tomography, a ureteral tumor was found in both the left distal ureter and left hydronephrosis. The ureteral tumor was pathologically diagnosed by ureteroscopic biopsies as metastatic RCC, consistent with the primary renal tumor. Partial ureterectomy and end-to-end uretero-ureterostomy were performed. Pathologic examination of the resected tumor confirmed metastatic RCC. The post-operative course has been uneventful, and to date, the patient has remained disease-free.

Ureteroscopic Biopsy of Upper Tract Urothelial Carcinoma: Comparison of Basket and Forceps

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

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

Endoscopic Management of Intraluminal Ureteral Endometriosis

To present the largest experience on the ureteroscopic management of ureteral obstruction secondary to intraluminal endometrial implantation. We retrospectively evaluated patients who underwent ureteroscopic management of intraluminal endometriosis from 1996 to 2012. All patients were diagnosed with ureteroscopic biopsy and underwent at least 1 ureteroscopic ablation with a holmium YAG (Ho:Yag) laser. Patients were monitored for evidence of disease persistence, recurrence, or progression with computed tomography, sonography, renal scan, ureteroscopy, and retrograde urography. Success was defined as the complete eradication of ureteral endometriosis, resolution of symptoms, and maintenance of renal function. Five patients were identified. Mean age was 37.5 years. All patients had hydroureteronephrosis at presentation whereas 2 had severely impaired renal function. Three patients were successfully treated with a single ablative procedure, whereas 2 had persistent symptomatic hydroureteronephrosis and underwent repeat ablation. Of those requiring repeat ablation, 1 became disease-free after the second ablation, whereas the other had persistence of disease, requiring nephroureterectomy. Three patients developed ureteral strictures, requiring balloon dilation and serial stent exchanges. At a median follow-up of 35 months (16-84), overall success rate was observed in 4 of 5 patients (80%). Endometriosis affects approximately 15% of premenopausal women and can present anywhere along the urinary tract including the ureters, which might result in urinary obstruction and impaired renal function. Although surgical resection is the conventional treatment option for intraluminal endometriosis, ureteroscopic management is a viable nephron-sparing alternative. Follow-up imaging, including ureteroscopic surveillance and retrograde urography is recommended to detect disease recurrence or progression, or both.

694 DOES TUMOR SIZE INFLUENCE THE ACCURACY OF URETEROSCOPIC BIOPSY FOR UPPER TRACT UROTHELIAL CARCINOMA?

You have accessJournal of UrologyUrothelial Cancer: upper Tract Tumors (I)1 Apr 2013694 DOES TUMOR SIZE INFLUENCE THE ACCURACY OF URETEROSCOPIC BIOPSY FOR UPPER TRACT UROTHELIAL CARCINOMA? Sima Porten, Andrew Park, Charles Guo, Lianchun Xiao, Ashish Kamat, and Surena Matin Sima PortenSima Porten Houston, TX More articles by this author , Andrew ParkAndrew Park Houston, TX More articles by this author , Charles GuoCharles Guo Houston, TX More articles by this author , Lianchun XiaoLianchun Xiao Houston, TX More articles by this author , Ashish KamatAshish Kamat Houston, TX More articles by this author , and Surena MatinSurena Matin Houston, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.250AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Select low grade tumors of the upper urinary tract can be effectively managed with nephron-sparing endoscopic therapy. Unfortunately, some patients that present with low grade disease based on current staging paradigms are upgraded/staged after surgery. We examine clinicopathologic factors associated with accuracy of diagnostic biopsy for upper tract urothelial carcinoma (UTUC). METHODS Clinicopathologic records of patients diagnosed with UTUC and treated surgically by a single urologist without neoadjuvant systemic therapy were reviewed. Clinical cTx staging was assigned when no degree of invasion was apparent on biopsy and imaging findings. All pathologic specimens were re-reviewed by an experienced genitourinary pathologist (CG) and tumor size was assessed by 4 types of measurement 1) surface area (cm2) 2) index volume (cm3) 3) aggregate volume (cm3) 4) index tumor single dimension (cm). Diagnostic biopsy grade (bG) was compared with pathologic grade (pG) and stage with McNemarÆs test ofagreement. FisherÆs exact or Wilcoxon rank sum was used to determine the association of clinical and pathologic features to changes in grade and stage. RESULTS We identified 66 patients meeting inclusion criteria. The majority were male (61%) and Caucasian (92%), with mean age of 74.6 years (SD 9.9). Table 1 outlines characteristics of diagnostic biopsies. 17 of 40 patients (43%) were upgraded and 2 of 26 (8%) were downgraded at nephroureterctomy (NU). Overall, bG was significantly different from pG (p=0.006) or stage (p=0.025). The predictive value of low bG for non- invasive disease at NU was 80% and the predictive value of high bG for muscle invasive disease at NU was 62%. Age, sex, clinical stage, multifocality were not associated with change in bG. In cTx patients tumor surface area was significantly associated with higher pT stage (p=0.0492). Patients with low bG found to have advanced stage at NU had a significantly (p=0.049) higher tumor surface area (median 15, 3-211) than those not upstaged (median 8.1, 0.8-27), and were more likely to have an index tumor dimension >3.8cm. CONCLUSIONS Overall, low bG can predict candidates without invasive disease for nephron sparing therapy in 80% of cases. In cTx patients with low bG, tumor surface area <8.1cm2 and dimension <3.8cm may help select those least likely to be upstaged. Table 1. Pathologic Characteristics at Diagnostic Biopsy N(%) N (%) Clinical Stage Pathologic stage Tx (unable to assess) 30 (46) Ta 26 (40) Non-Invasive (Ta-1,cis) 35 (53) T1 16 (24) Invasive (T2+) 1 (1) T2+ 24 (36) Grade Pathologic grade Low 40 (61) Low 25 (38) High 26 (39) High 41 (62) Multifocality No 51 (77) Yes 15 (23) Table 1. Pathologic Characteristics at Diagnostic Biopsy Mean SD Median Range Surface area (cm2) 14.9 26.3 8.4 0.4-210.6 Index volume (cm3) 47.9 187.5 12.2 0.1-1474.2 Aggregate volume (cm3) 48.7 187.4 12.2 0.1-1474.2 Index diameter (cm) 4.7 3.5 3.8 0.7-23.4 © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e285 Peer Review Report Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sima Porten Houston, TX More articles by this author Andrew Park Houston, TX More articles by this author Charles Guo Houston, TX More articles by this author Lianchun Xiao Houston, TX More articles by this author Ashish Kamat Houston, TX More articles by this author Surena Matin Houston, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Utility and Diagnostic Accuracy of Ureteroscopic Biopsy in Upper Tract Urothelial Carcinoma

Ureteroscopic biopsy is the gold standard for the histopathologic diagnosis of urothelial carcinoma of the upper urinary tract. To assess the accuracy of endoscopically obtained biopsy samples in diagnosing, grading, and staging urothelial carcinoma and correlate diagnostic findings to biopsy sample size. We retrospectively reviewed endoscopic biopsies of the ureter, renal pelvis, and ureteropelvic junction from 2008 to 2011. Biopsy diagnoses that were discordant with follow-up pathology and/or ureteroscopic impression were re-reviewed and samples were immunohistochemically analyzed. Endoscopic biopsies (n = 118) yielded a sensitivity of 85.4% for the ureter (n = 79), 77.8% for the renal pelvis (n = 37), and 100% for the ureteropelvic junction (n = 2). A specificity of 100% for all locations and a diagnostic accuracy of 98.3% were identified. The median sample size was 0.3 cm for true positives, 0.3 cm for true negatives, and 0.2 cm for false negatives with no statistical significance. We found that 87.1% of tumors diagnosed on biopsy had concordant grade and 60.0% had concordant pT stage with follow-up surgical resections (n = 43) and biopsies (n = 24). Biopsy samples with concordant tumor grades (mean = 0.6 cm) compared with follow-up resection were larger than biopsy samples with discordant grades (mean = 0.3 cm) (P = .04). Though highly specific, endoscopic biopsy does provide a significant false-negative rate owing to both sampling and diagnostic errors when assessing the upper urinary tract for urothelial carcinoma. Tumor grading is accurate, particularly with larger tissue samples, but tumor staging is unreliable.

Renal Leiomyosarcoma: A Diagnostic Challenge

Renal leiomyosarcoma is a very rare tumor that clinically and radiographically mimics more common renal malignancies. The infrequency of the condition makes it very difficult to diagnose. A 70-year-old male smoker presented with months of hematuria, right-sided flank pain, and weight loss. Imaging revealed a 3.8-centimeter renal mass that had characteristics similar to renal cell carcinoma. Initial biopsy of the mass was negative for malignancy. Two months later, subsequent imaging revealed what appeared to be metastatic bone lesions. Again, a biopsy of one of the lesions was negative for malignancy. Subsequent ureteral pyeloscopy, ureteroscopic renal pelvis biopsy, and brush cytology were negative for malignancy as well. The decision was made to perform nephrectomy for the removal of the mass. Pathologic analysis revealed renal leiomyosarcoma. This case illustrates the difficulty in diagnosing renal leiomyosarcoma. Repeated pathologic sampling was negative because of the tumor heterogeneity. Prompt diagnosis and treatment are very significant as surgical resection at an early stage offers the best prognosis.

Significance of Ureteroscopic Biopsy Grade in Patients with Upper Tract Urothelial Carcinoma

Background: The objective of this study was to assess the significance of the ureteroscopic biopsy grade for patients with upper tract urothelial carcinoma (UTUC). Patients and Methods: This study included 40 patients who were diagnosed with a single focus of UTUC by ureteroscopic biopsy and subsequently underwent nephroureterectomy. The significance of the biopsy grade as a predictive factor for pathological outcomes of nephroureterectomy was retrospectively analyzed. Results: Of these 40 patients, 19 (47.5%) and 21 (52.5%) were diagnosed with low and high grade UTUC, respectively. The ureteroscopic biopsy grade matched the pathological grade of surgically resected specimens in 35 of the 40 cases (87.5%), and there was a significant correlation between the biopsy and pathological grades (p < 0.001). Furthermore, the biopsy grade was also shown to be closely associated with the pathological stage (p < 0.001); that is, only 1 of the 19 patients (5.3%) with biopsy low grade UTUC were pathologically diagnosed as having muscle invasive disease, while 17 of the 21 patients (81.0%) with biopsy high grade UTUC appeared to show tumor invasion into muscle or deeper. Conclusions: The grade of UTUC on ureteroscopic biopsy could provide accurate diagnostic information on the final pathology of nephroureterectomy specimens.

Endoscopic Versus Laparoscopic Management of Noninvasive Upper Tract Urothelial Carcinoma: 20-Year Single Center Experience

We compare the outcomes of endoscopic surgery to laparoscopic nephroureterectomy for the management of specifically noninvasive upper tract urothelial carcinoma. A retrospective database review identified consecutive patients with clinically noninvasive upper tract urothelial carcinoma who underwent endoscopic surgery (59, via ureteroscopic ablation or percutaneous resection) or laparoscopic nephroureterectomy (70) at a single center during 20 years (1991 to 2011). Overall survival, upper tract urothelial carcinoma specific survival, upper tract recurrence-free survival, intravesical recurrence-free survival, progression-free survival and renal unit survival were estimated using Kaplan-Meier methods, with differences assessed using the log rank test. Median age and followup were 74.8 years and 50 months, respectively. Overall renal preservation in the endoscopic group was high (5-year renal unit survival 82.5%), although this came at a cost of high local recurrence (endoscopic surgery 5-year recurrence-free survival 49.3%, laparoscopic nephroureterectomy 100%, p <0.0001). For G1 upper tract urothelial carcinoma, endoscopic surgery 5-year disease specific survival (100%) was equivalent to that of laparoscopic nephroureterectomy (100%). However, laparoscopic nephroureterectomy demonstrated superior disease specific survival to endoscopic surgery for G2 disease (91.7% vs 62.5%, p = 0.037) and superior progression-free survival for G3 disease (88.9% vs 55.6%, p = 0.033). For G1 upper tract urothelial carcinoma, endoscopic management can provide effective oncologic control and renal preservation. However, endoscopic management should not be considered for higher grade disease except in compelling imperative cases or in patients with poor life expectancy as oncologic outcomes are inferior to those of laparoscopic nephroureterectomy.

Low biopsy volume in ureteroscopy does not affect tumor biopsy grading in upper tract urothelial carcinoma

ObjectivesUrothelial carcinomas (UC) from the upper urinary tract represent 7%–10% of all kidney malignancies. With current ureteroscopic (URS) techniques, small tissue samples are usually the only available histopathologic material for evaluation, representing a diagnostic challenge. Precision in diagnosis is essential for treatment decision making. There has been much debate as to whether tumor grade and stage found on biopsy agree with final pathology. The purpose of this study is to evaluate whether URS biopsy volume affects tumor grading and staging agreement between biopsy and nephroureterectomy (NU) specimens. Materials and methodsWe reviewed 137 URS biopsies in 81 patients with suspected upper urinary tract UC performed from April 2002 to April 2011. Of those, 54 patients had both the URS biopsy and NU performed at our institution and were available for review. Biopsy dimensions were recorded to calculate estimated ellipsoid volume, and 2 urological pathologists independently evaluated histologic grade (ISUP/WHO 2004), (based on pleomorphism and mitosis) and depth of invasion. Statistical analysis was performed to evaluate URS biopsy and NU specimen grade and stage concordance. In addition, univariable and multivariable analyses was performed to assess the effect of biopsy volume on agreement. ResultsOf the 54 patients studied, low grade and high grade UC biopsy were found in 8 (15%) and 46 (85%), URS biopsies, respectively. Regarding biopsy stage, 51 (94%), 1 (2%), and 2 (4%) were stage Ta, T1, T2, respectively. Grade concordance was 92.6%, (95% CI: 82.4%–98.0%). Stage concordance was 43% (95% CI: 28.7%–55.9%). Multivariable analysis showed biopsy volume did not affect tumor assessment of grade (P = 0.81) or stage (P = 0.44). ConclusionsHistologic grade assigned on the URS biopsy sample accurately predicts histologic grade in the resected specimen (92.6%), even when the biopsy volume is small. Grading in URS biopsies provides sufficient information for clinical decision making that is independent of sample volume.

Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review

What's known on the subject? and What does the study add? Endoscopic management of upper tract urothelial carcinoma (UTUC) using either ureteroscopy and laser ablation, or percutaneous resection, is a management option for treating selected low-grade tumours with favourable characteristics. However, the evidence base for such practice is relatively weak, as the reported experience is mainly limited to small case series (level of evidence 4), or non-randomised comparative studies that are unmatched for tumour stage (level of evidence 3b), with variability of follow-up duration and reported outcome measures. The present systematic review comprehensively reviews the outcomes of all studies of endoscopic management of UTUC, including the role of topical adjuvant therapy. It establishes for the first time a structured reference for endoscopic management of UTUC, and is a foundation for further clinical studies. To systematically review the oncological outcomes of upper tract urothelial carcinoma (UTUC) treated with ureteroscopic and percutaneous management. The standard treatment of UTUC is radical nephroureterectomy (RNU). However, over the last two decades several institutions have treated UTUC endoscopically, either via ureteroscopic ablation or percutaneous nephroscopic resection of tumour (PNRT), for both imperative and elective indications. For evidence acquisition the Pubmed database was searched for English language publications in December 2011 using the following terms: upper tract (UT) transitional cell carcinoma (TCC), upper tract TCC, UTTCC, upper tract urothelial cell carcinoma, upper tract urothelial carcinoma, UTUC, endoscopic management, ureteroscopic management, laser ablation, percutaneous management, PNRT, conservative management, ureteroscopic biopsy, biopsy, BCG, mitomycin C, topical therapy. There are no randomised trials comparing endoscopic management with RNU. Most published studies were retrospective case series (and database reviews), or unmatched comparative studies. There was strong selection bias for favourable tumour characteristics in many endoscopically treated groups. There was variation in medical comorbidity and indication for treatment across different study groups. The biopsy verification of underlying UTUC pathology was inconsistent. The follow-up in most studies was limited, typically to a mean 3 years. There is a high rate of UT recurrence with endoscopically managed UTUC, and a grade-related risk of tumour progression and disease-specific mortality. Overall, renal preservation may be high with ≈20% of patients proceeding eventually to RNU. For highly selected Grade 1 (or low-grade) disease managed in experienced centres, 5-year disease-specific survival (DSS) may be equivalent to RNU, although the small study groups and short follow-ups preclude comments on less favourable Grade 1 (or low-grade) tumour characteristics, or DSS, in the longer-term. For Grade 3 (or high-grade) disease, DSS outcomes are poor and endoscopic management should only be considered for compelling imperative indications in the context of the patient's overall life expectancy and competing comorbidity.

High-Grade Ureteroscopic Biopsy Is Associated with Advanced Pathology of Upper-Tract Urothelial Carcinoma Tumors at Definitive Surgical Resection

Accurate assessment of upper-tract urothelial carcinoma (UTUC) pathology may guide use of endoscopic vs extirpative therapy. We present a multi-institutional cohort of patients with UTUC who underwent surgical resection to characterize the association of ureteroscopic (URS) biopsy features with final pathology results. URS biopsy data were available in 238 patients who underwent surgical resection of UTUC. Biopsies were performed using a brush biopsy kit, mechanical biopsy device, or basket. Stage was classified as a positive brush, nonmuscle-invasive (<pT(2)), or muscle invasive (MI; ≥pT(2)). Grade was classified as low or high. On URS biopsy, 88/238 (37%) patients had a positive brush, 140 (59%) had a diagnosis of non-MI, and 10 (4%) had MI disease. Biopsy results showed low-grade cancer in 140 (59%) and high-grade cancer in 98 (41%). Pathologic evaluation at surgical resection demonstrated non-MI tumors in 140 (59%) patients, MI in 98 (41%), and high-grade disease in 150 (63%). On univariate analysis, high URS biopsy grade was associated with high-grade (positive predictive value [PPV] 92%, P<0.0001) and MI (PPV 60%, P<0.0001) UTUC at surgery. URS biopsy stage, however, was associated with surgical pathology grade (P=0.005), but not MI (P=0.16) disease. On multivariate analysis, high URS grade, but not biopsy stage, was associated with high final pathology grade (hazard ratio [HR] 16.6, 95% confidence interval [CI] 7.0-39.5, P<0.0001) and MI UTUC (HR 3.6, 95% CI 2.1-6.8, P<0.0001). High URS biopsy grade, but not stage, is associated with adverse tumor pathology. This information may play a valuable role for risk stratification and in the appropriate selection of endoscopic management vs surgical extirpation for UTUC.