Endoscopic Approaches to Upper Tract Urothelial Carcinoma

In this article review, the strategies of endoscopic management of upper tract urothelial carcinoma, including diagnosis, treatment, and surveillance were summarized. Diagnostic ureteroscopy has been shown to shift management towards less invasive means. Many have demonstrated the lack of metastatic potential related to pyelovenous backflow during ureteroscopy. To optimize results of the biopsy, standard biopsy techniques and specimen processing should be adhered to. Urine cytology, although with poor sensitivity, can serve as an adjunct test to ureteroscopic biopsy to improve prognostic accuracy, primarily to confirm the high-grade disease. FISH is a urine-based cytogenetic test demonstrating high sensitivity. However, whether it can be used instead of diagnostic ureteroscopy remains to be seen. In addition, nomograms can be used to incorporate biopsy results and other factors to predict for non-organ confined Upper Tract Urothelial Carcinoma (UTUC), pointing to the need for neoadjuvant chemotherapy.

As for the treatment of UTUC, there are imperative (solitary kidney, bilateral tumor, and poor candidacy for dialysis/transplant) and elective indications (low grade, low volume, non-invasive tumors) for kidney-sparing therapy. Ureteroscopic treatment should be preceded by biopsy using one of the commonly used tools (3-F cup biopsy forceps, BIGopsy, 1.7F nitinol basket, a steel wire basket). Ureteral access sheath should be utilized whenever possible to provide multiple passes to the tumor for adequate sampling, and facilitating irrigation. Laser ablation can be performed using the holmium: YAG laser for small, superficial tumors and Nd: YAG laser for larger tumors, if available. With improving ureteroscopic technology, the incidence of ureteral injury has drastically decreased. Adjunct techniques include ureteroscopic fulguration of the tumor using Bugbee electrode. Recurrence rates in the upper tract and bladder after endoscopic treatment range from 52-65% and 34-44%, respectively. Percutaneous treatment of upper tract tumor is reserved for anatomically challenging tumors. However, this technique is associated with increased invasiveness and perioperative morbidity. Adjuvant therapy after endoscopic management is incorporated to reduce recurrence, using chemotherapy or BCG, while primary management of upper tract CIS utilizes BCG. Adjuvant therapy is most reliably administered in a retrograde fashion via a single-J stent or open-ended ureteral catheter or in antegrade fashion via a nephrostomy tube. Experiments conducted using an ex-vivo model demonstrated most effective surface area coverage using the retrograde instillation. Given the relatively high incidence of recurrence, surveillance using cross-sectional imaging and ureteroscopy are imperative.

Written by: Roger Li, MD, Firas Petros, MD, and Surena F. Matin, MD, Department of Urology, UT MD Anderson Cancer Center

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