Management of Upper Tract Urothelial Carcinoma After Radical Cystectomy with Urinary Diversion 

( The 2021 American Urological Association (AUA) Summer School session on Upper Tract Urothelial Carcinoma included a case-based discussion led by moderator Dr. Surena Matin who was joined by panelists Dr. Sima Porten and Dr. Vitaly Margulis. This case focused on the management of upper tract urothelial carcinoma in the setting of a previous cystectomy with neobladder urinary diversion. The patient was a 75-year-old male who previously underwent a radical cystectomy, bilateral pelvic lymphadenectomy with a Studer pouch for BCG refractory bladder CIS, final pathology pTispN0R0. Surveillance imaging demonstrated left hydronephrosis and a soft tissue lesion in the left ureter. His GFR had previously been 47, but had recently decreased to 22 in the setting of worsening Parkinson’s disease and dementia:

He subsequently underwent a percutaneous nephrostomy tube placement with recovery of his GFR to ~45-49. At the same time as the tube placement, interventional radiology was able to obtain a percutaneous biopsy of the ureteral lesion demonstrating poorly differentiated carcinoma compatible with urothelial primary carcinoma. He then underwent four cycles of neoadjuvant cisplatin plus gemcitabine plus ifosfamide, and restaging CT scan after three cycles showed an appropriate response. He then underwent a right nephroureterectomy with excision of the cuff of the pouch and retroperitoneal lymph node dissection. His final pathology was ypT0 ypN0/3 and a post-operative GFR of 22. Dr. Matin then posed the following questions to his panel:

  1. Why use a percutaneous biopsy?
  2. What is the safety and diagnostic reliability of a percutaneous biopsy?

Dr. Porten states that the benefit of a percutaneous biopsy is ideal at the time of percutaneous nephrostomy tube placement since it is inherently difficult to obtain tissue in a patient after a cystectomy and neobladder urinary diversion (thus favoring an antegrade access approach). Dr. Margulis added that after the percutaneous nephrostomy tube is placed a urine cytology can be obtained and if that is positive it is diagnostic enough to confirm an upper tract urothelial carcinoma diagnosis. Dr. Matin highlighted that he is perhaps “old school” in his thinking given that it makes him nervous to do a biopsy in the setting of a fresh nephrostomy tract, thus he will leave the nephrostomy tube in for one week and then come back and do the antegrade biopsy thereafter.

Moderator: Surena F. Matin, MD, MD Anderson Cancer Center, Houston, TX

Panelists: Sima Porten, MD, MPH, University of California – San Francisco, San Francisco, CA & Vitaly Margulis, MD, UT Southwestern, Dallas, TX

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the AUA2021 May Kick-off Weekend May 21-23.