Endoscopic diagnosis of upper-tract TCC – Correlating indications, investigations and histology Finch W, Shah N, Wiseman O Addenbrooke’s Hospital Cambridge

Endoscopic diagnosis of Upper-tract TCC Confirm Diagnosis prior to Nephroureterectomy  10.2% - Benign disease Increasing pressure for nephron sparing endoscopic approaches  Solitary kidney, bilateral tumours, renal impairment  High surgical risk patient  Low grade low stage tumours Traditionally difficult to assess upper tract stage with imaging Ureteroscopic biopsies – accurate?  75% accurate in predicting upper-tract TCC grade  Biopsy grade can predict pathological stage Chitale et al. Ann R Coll Surg Engl 2008;90:45-50 Williams et al. J Endourol 2008;22:71-75 Keeley et al. J Urol 1997;157:

Study Aims Evaluate  Indications for referral  Accuracy of ureteroscopy in staging upper-tract TCC Ureteroscopic findings Upper-tract urine cytology Ureteroscopic biopsy  Correlate with Final surgical histology

Study Cohort 85 patients  55M : 30F  Average age 68 yrs (range 28-98)  75 Routine diagnostic  10 Complex diagnostic conduit / distal ureterectomy / horseshoe kidney

Indications for referral and diagnosis

Cohort Outcome 85 patients referred for endoscopic diagnosis of upper-tract TCC 45 patients No evidence of upper-tract TCC 40 patients Upper-tract TCC 18 patients Nephroureterectomy 3 patients Awaiting Nephroureterectomy 15 patients Endoscopic Management 4 patients Declined treatment Palliative Care 45 patients Discharged Back to referring clinician

Ureteroscopic findings and final histology Uretero-ileal anastamosis – 4% TCC not visualised – 5% Stricture Tortuous upper ureter Renal Upper pole – 10% Renal Interpolar – 4% Renal Lower pole – 8% Renal Pelvis – 22% Renal Extensive – 8% Ureter Upper 1/3 – 0% Ureter Middle 1/3 – 8% Ureter Lower 1/3 – 26% Ureter Extensive – 5% When TCC seen endoscopically ALL final histology confirmed TCC

Pathological grade Upper-tract cytology and Pathological grade

Ureteroscopic biopsy grade and Pathological grade Pathological grade

Ureteroscopic biopsy grade and Pathological stage Pathological stage

Pathological stage Positive endoscopic investigations and Surgical grade

Conclusions Failure to investigate endoscopically may result in unnecessary procedures for benign disease Filling defects on prior imaging - No TCC demonstrated in 66% cases Ureteroscopically - if it looks like TCC – it usually is Upper-tract urine cytology helps identify high grade disease Ureteroscopic biopsy is not always accurate - but can predict high grade disease The combination of ureteroscopic appearance, cytology and biopsy 1.will diagnose upper-tract TCC 2.may help identify patients not suitable for conservative therapy