AUA 2019: The Crucial Role of Ureteroscopy in the Diagnostic/Therapeutic Pathway of Upper Tract Urothelial Carcinoma

Chicago, IL ( Dr. Boissier presented a study on the crucial role of ureteroscopy in the diagnostic/therapeutic pathway of upper tract urothelial carcinoma (UTUC). According to the European Association of Urology guidelines, UTUC is divided into low and high-risk tumors (see figure 1). In low-risk UTUC, treatment with kidney-sparing procedures is quite similar to radical nephroureterectomy and result in 77% local recurrence rate, 15% progression, and 17% of patients requiring salvage radical nephroureterectomy. The question of staging is repeated during follow-up. In high-risk UTUC, the cancer-specific survival in kidney-sparing procedures is lower than for radical nephroureterectomy. Some of the common pitfalls that occur in the management of UTUC is based only on CT scans and not ureteroscopy as shown in figure 2.

Figure 1 – EAU definition of low and high-risk disease:

AUA 2019 EAU definition of low and high risk disease

Figure 2  Common pitfalls in the management of UTUC based on CT scans alone:

AUA 2019 pitfalls in the management of UTUC

The objectives of these studies include the assessment of the staging accuracy of CT urography vs. ureteroscopy, and to understand how it influences the treatment strategy. This study took place between 2015 and 2018 and included 101 patients with available CT, who were submitted to ureteroscopy for suspicion of UTUC. CT scans were performed within 40 days before surgery and were categorized as either positive or negative. The authors assessed the correlation between imaging and ureteroscopy and histology.

The results demonstrated that in 24% of the patients the CT scan was negative, but in 15/24 (62.5%) of these patients, a tumor was confirmed in pathology. In the 77% of patients that had a positive scan, all patients had a visible lesion on ureteroscopy and 72/77 patients this was confirmed on cytology/pathology. Of the 72 patients that had a final pathology of UTUC, 32 patients (44.4%) had different tumor characteristics compared to those shown on CT scan. The sensitivity and specificity of the CT was 46% and 64%, respectively. The correlation of CT findings to the ureteroscopy findings is shown in figure 3. The median follow-up was 13 months.

Figure 3 – Correlations between CT scans and ureteroscopy:

AUA 2019 Correlations between CT scans and ureteroscopy

The limitations of this study included the real-life quality of CT urography, the relatively low number of patients and the short follow-up. Dr. Boissier concluded that CT accuracy in characterizing UTUC lesions is quite low. Ureteroscopy should be considered a crucial step in the diagnostic pathway of UTUC, even in the case of CT-documented high-risk tumors. Ureteroscopy may significantly change the treatment indication.

Presented by: Romain Boissier, MD, Fundacio Puigvert, Barcelona 

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter: @GoldbergHanan at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois
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