FOIU 2018: Ureteoscopic Management of Upper Tract UC: Time to Update the Guidelines?

Tel-Aviv, Israel ( Scott Hubosky, MD, began his talk with the change that the current European Urology guidelines have made regarding the indication for kidney preservation treatment for low-grade upper tract urothelial carcinoma (UTUC). The change from 2015 to 2018 is that the upper limit of tumor size increased from 1 cm to 2 cm. Dr. Hubosky recommends a risk-adapted strategy for kidney-sparing management of upper tract tumors. According to this approach, only low risk ureteral and renal pelvis UTUC, or highly selected cases of high-risk renal pelvis tumors (large, multifocal tumors with low grade and superficial features) are suitable for this conservative approach in patients with elective indications.1 

Dr. Hubosky then presented a study of 92 UTUC patients with a median tumor size of 14 mm (1-30 mm) treated with holmium laser, with a median follow-up of 52.4 months. The results showed a recurrence rate of 76%.2 Another study presented, assessed the capability of ureteroscopy in treating UTUC of index lesions 2 cm or greater.3 Overall, there were 63 patients, with a mean tumor size of 31 mm (20-60), with 42/63 being at the renal pelvis, 23/63 located at the ureter, and 4/63 located in both. According to the results, the index lesion was treated in all patients, with a mean number of 1.69 ureteroscopies needed to clear the lesion. In 71% of the cases, 2 ureteroscopies were needed to clear the lesion. It is therefore imperative that a 2nd look ureteroscopy is performed within 4-6 weeks of the 1st procedure. The mean follow-up was 44 months (3-177), and local recurrence rate was 91%, with a mean time to first recurrence of 4.9 months. Postoperative bladder recurrence occurred in 30% of patients, and progression to high-grade disease occurred in 17% of patients, with mean time to grade progression being at 26.3 months. A total of 25% of patients progressed to radical nephroureterectomy (RNU), and total progression occurred in 31%. Several additional relevant studies with the results are shown in table 1.

Table 1  - Comparison of UTUC endoscopic treatment series:

Dr. Hubosky continued and discussed the usage of lasers in ureteroscopy for UTUC treatment. According to him, a combination of both holmium:YAG and ND:YAG is the best. This allows both coagulation (tissue destruction and hemostasis) and ablation (removal of tissue and assessment of treatment). The holmium:YAG has a 0.5 mm depth of penetration, and a wavelength of 2140 nm, allowing for both ablation and coagulation. On the other hand, the ND:YAG has a wavelength of 1064 nm, with 5 mm depth of penetration, and excellent coagulation.

Another tip given by Dr. Hubosky to urologists endoscopically treating UTUC disease is to add small amounts of water when there is difficulty in visibility due to bleeding. This enables absorption of the blood and improves visibility.

Dr. Hubosky concluded his great talk with some important observations:

  1. For lesions >2 cm, it is imperative to perform a 2nd look within 4-6 weeks from the first ureteroscopy
  2. Better results are seen with the use of modern pathology grading system (2004 vs. 1973). 
  3. Usage of all available tools will improve results. These include dual laser, Bugbee, water, and Mitogel.
  4. Treatment of larger tumors lends to a higher rate of local recurrence, progression, and renal unit loss.
  5. It important to carefully select the patients for this treatment, provide appropriate preoperative counseling, and frequent surveillance.

Presented by: Scott Hubosky, Thomas Jefferson University Hospital, Philadelphia, PA, USA

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 FOIU 4th Friends of Israel Urological Symposium, July 3-5. 2018, Tel-Aviv, Israel

  1. Seisen et al. 2015 Nat Rev Urol (12) 155-166
  2. Villa et al. 2018 J Urol 199 (1) 66-73
  3. Scotaland & Kleinmann et al. 2018 Urology in press