- UTUC accounts for 5-10% of all urothelial carcinoma
- Flexible URS (ureteroscopy) allows visualization of 95% of the upper tract
- FURS allows for visualization, diagnosis, endoscopic ablation and treatment of UTUC
- It is invaluable in patients with indications for kidney sparing surgery
Combining FURS / imaging findings + biopsy grade + urine cytology are key for risk stratification.
He addressed three specific topics today:
1) Imaging/Visualization – specifically methods to improve visualization, improve histopathologic prediction
2) Biopsy techniques
3) Second Look – current role
Imaging/Visualization
First, he emphasized the “no touch” technique – evaluation of the upper tract with as little manipulation as possible prior to any interventions.
- Try and evaluate the upper tract with FURS without place wire first, definitely without an access sheath first
- Less instrumentation prior to first look with FURS will limit false negatives (erythema, bleeding) and compromised visualization
1. Narrow band imaging – enhance contrast of mucosal surfaces and vascular structures, potentially improving detection rate
2. Storz professional imaging enhancement system (SPIES) - enhance contrast of mucosal surfaces and vascular structures, potentially improving detection rate
3. Photodynamic diagnosis – similar to bladder. Uses fluorescence to improve tumor detection rate.
acute angles of FURS increases false positives!
5-ALA can be given orally 3-4 hours prior for better utility
4. Confocal laser endomicoscopy (CLE) – allows high-resolution microscopy of tissue resulting in images of cellular structure, high grade concordance with final pathology.
5. Optical Coherence Tomography (OCT) – cross-sectional high-resolution images. Provides information regarding tumor grade and stage.
All of these are valuable in specific clinical scenarios.
Biopsy – Objective is get proper grade not stage!
Biopsy can determine grade (but not stage) in 90% of tumors with a low false-negative rate
Undergrading remains an issue – hence, intense follow-up is needed.
- FURS missed concomitant CIS (compared to radical nephroureterectomy specimens)
- 17-80% of grade 2 tumors vary from low-stage to high-stage! Grade 1 and 3 are more reliable
Biopsy tools:
1. Baskets – two forms – flat wire (good for ureter and renal pelvis, no hematuria), nitinol tip (good for calyceal tumors, moderate hematuria)
2. Cup biopsy forceps
3. Coaxial 3 way prong
4. Big-opsy forceps: front-loaded, need to have ureteral access sheaths – but gets big samples
5. Access sheath: facilitates multiple biopsies (89% concordance)
He prefers to use baskets and prongs. Baskets can get more tissue.
Recommends push-technique – pushing forward with prongs into papillary tumor often gets the bulk of the tumor rather than pulling out. Specimen less likely to be dislodged from the prongs.
Second-look URS
Guideline recommendations for 2nd look URS 2-3 months after first.
Ensures adequate patient stratification and selection for conservative management.
Improves oncologic outcomes
- Patients with early recurrence do much more poorly than those who are free of disease
- Similar to 1st post-BCG cystoscopy in terms of prognostication
Presented by: C.C. Seitz
Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark