Ureteroscopic Management of Large ≥ 2 cm Upper Tract Urothelial Carcinoma: A Comprehensive Twenty-three Year Review – Beyond the Abstract

Introduction: Upper tract urothelial carcinoma (UTUC) accounts for less than 10% of renal tumors and 5% of all urothelial tumors. While it is a relatively rare disease, survival rates are often poor, particularly in patients with advanced disease. Traditionally, patients with large (UTUC) have been treated with radical nephroureterectomy (RNU). However, advancements in ureteroscope technology and innovations in ancillary equipment have led to the increasing use of ureteroscopy in the diagnosis as well as the management of small low-grade UTUC.  We hypothesized this modality is also a viable alternative to RNU in patients with large low-grade tumors. The aim of this study was to assess the effectiveness of ureteroscopy (URS) with laser ablation as a treatment for UTUC lesions larger than 2 cm.

Methods: An institutional database review was performed of patients managed initially by a single urologist and followed over a 23-year period. This evaluation identified 80 patients with biopsy-proven low-grade UTUC who had at least one lesion larger than 2 cm. We collected clinical data including demographics, operative parameters and pathologic features. A standardized protocol of tumor ablation was followed (see the accompanying video demonstrating ablation of an approximately 4cm tumor).  Follow-up for all patients was standardized and included cystoscopy and ureteroscopy every 3 months until clear, every 6 months through the fifth year and yearly thereafter. We calculated rates of recurrence, progression and overall survival.

Results: In the 80 qualifying patients a total of 86 unique lesions ≥ 2cm were identified with a mean tumor size of 3.04 cm. Median follow-up was 43.6 months. During follow-up of patients treated curatively, 90.5% of tumors had ipsilateral recurrence and 31.7% progressed in grade at a median of 26.3 months. RNU was performed in 16 patients (20%) with a mean time to surgery of 23.2 months.  Overall survival was 75% and cancer-specific survival was 84% at five-year follow-up.

Conclusions: Due to the relative infrequency of patients with ≥ 2 cm tumors, this study presents one of the largest sample sizes of ureteroscopically managed patients, their demographics, and outcomes in the literature to date.  Based on these findings, our management has changed. The initial surveillance is now performed at 6–8 weeks after treatment. If the patient is clear of tumor at this episode, then a three-month schedule is started. We have also expanded the biopsy technique. We have always taken multiple biopsies, but now sample several different areas of the tumor and obtain samples during treatment as additional portions of the tumor are exposed. Under a strict surveillance protocol, ureteroscopic management of large UTUC lesions ≥ 2cm is a safe and efficacious alternative to the current standard of RNU in well-selected patients. While recurrence is more common than seen with smaller tumors, ureteroscopy can potentially preserve renal units, avoid complicated surgical procedures and lessen tumor burden in patients with large lesions. 

Written by: Kymora B. Scotland MD,PhD, Nir Kleinmann MD, Dillon Cason BS, Logan Hubbard BS, Ryuta Tanimoto MD, Ph.D., Kelly A. Healy MD, Scott G. Hubosky MD  and Demetrius H. Bagley MD

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