EAU 2018: Challenges in Flexible Endoscopy

Copenhagen, Denmark (UroToday.com)  Dr. Seitz started off the thematic session on “Challenges in Upper Urinary Tract Urothelial Cancer” with challenges in flexible endoscopy. Upper Urinary Tract Urothelial Carcinoma (UTUC) remains a challenge to manage due to the relative rarity of the disease, the difficulties with tissue acquisition and imaging, and difficulties with reliable staging.

  • 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
Current EAU management algorithm (Roupret 2015)

Challenges in flexible endoscopy1

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


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
New optical diagnostics have potential for less invasive diagnosis of UTUC:

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
Non-diagnostic tissue in up to 25-31% of patients

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