1. Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas
Dept. of Urology
Centro Hospitalar do Porto
March 11th, 2017

2. UTUC Epidemiology Location Invasive 2/3 5-10% 60% 1/3 90-95% 15-25%
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

3. UTUC Epidemiology Synchronicity Recurrence 2-6% 17% 2% 22-47% 2%
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

4. UTUC
Radical nephroureterectomy with bladder cuff excision (+/- lymph node dissection)
Gold standard
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

5. Gold standard
Radical nephroureterectomy with bladder cuff excision (+/- lymph node dissection)
But…
Perioperative complications: 26%
26% Clavien ≥ III
Mortality rate at 90 days: 4.4%
T1: 2.4%
G1/G2: 2.6%
45.1% for renal insufficiency
Raman et al. 2014
Urol Oncol
Jeldres et al. 2010
Urology
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

6. CKD and RNU eGFR (mL/min/1.73m2) n < 60, pre < 60, post
336
52%
78% -
388
51%
81%
20%
45%
414
76%
32%
66%
Lane et al. 2010
Cancer
Kaag et al. 2010
Eur Urol
Raman et al. 2014
Urol Oncol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

7. ESRD survival Pak et al. 2009 J Endourol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

8. Cost analysis Pak et al. 2009 J Endourol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

9. Conservative tx Imperative Elective Solitary functional kidney
Bilateral tumour
Preexisting CKD
Normal contralateral kidney
Patient selection
Accurate staging
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

10. Radical vs. conservative tx
No RCT’s
Only retrospective case series and non-randomised comparative studies
Selection bias
Variation in indication
Short or intermediate-term follow-up
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

11. Conservative tx Segmental ureterectomy
Partial nephrectomy / Pyelectomy
Percutaneous resection
Ureteroscopic ablation
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

12. Risk stratification – elective
Low-risk
High-risk
Low-grade ureteroscopic biopsy
Low-grade cytology
Tumour size < 1 cm
No invasive features on cross-sectional imaging
Unifocal disease
Close follow-up possible and acceptable to patient
High-grade ureteroscopic biopsy
High-grade cytology
Tumour size > 1 cm
Invasive features on cross-sectional imaging
Hydronephrosis
Multifocal disease
Failed endoscopic treatment of “low-risk tumour”
Previous bladder tumour/cystectomy
Smoking
Rouprêt et al. 2014
Eur Urol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

13. Staging Endoscopic Treatment of Upper Tract Urothelial Tumours
Uro-CT
Cytology
Biopsy
Treatment decision
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

14. Uro-CT Filling defect Wall thickening Hydronephrosis
Parenchymal invasion
Bard et al. 2017
Nat Rev Urol
van der Molen et al. 2008
Eur Radiol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

15. Before instrumentation
Urinary cytology
Selective, in situ
Before instrumentation
Suboptimal
Messer et al. 2011
BJU Int
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

16. Ureteroscopic biopsy Limitations Inadequate tissue volume
Artefacts (crushing)
Non-representative sampling
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

17. Ureteroscopic biopsy Rojas et al. 2013 Urol Oncol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

18. Ureteroscopic biopsy Suboptimal PPV 92% 60% Clements et al. 2012
J Endourol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

19. Ureteroscopic biopsy Routine diagnostic ureteroscopy
Decrease RNU from 89% to 69% (NNT = 5)
Decrease misdiagnoses from 15.5% to 2.1% (NNT = 7.5)
Tsivian et al. 2014
J Endourol
Technical success ≈ 95%
with flexible ureteroscopy
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

20. Prediction models PPV = 89% when all 3 present Brien et al. 2010
J Urol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

21. Prediction models AUC = 71% Favaretto et al. 2011 BJU Int
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

22. Flowchart Bard et al. 2017 Nat Rev Urol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

23. Endoscopic tx
URS ablation
n (% imperative)
736 (32)
Follow-up (median) in mo
14 – 73 (37)
Upper tract recurrence
53%
Bladder recurrence
34%
Overall survival
72%
Disease-specific survival
91%
Nephroureterectomy rate
19%
Progression
15%
Failed endo management
24%
Complication rate
14% #
Similar CSS after endoscopic treatment of low-grade non-invasive tumors, but increased risk of local recurrence
Seisen et al. 2016
Eur Urol
# 11% stricture
Cutress et al. 2012
BJU Int
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

24. Digital flexible ureteroscopy
Improving imaging
Digital flexible ureteroscopy
Bard et al. 2017
Nat Rev Urol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

25. NBI
5 additional tumours (14.2%) + extended limits of 3 tumours (8.5%) detected
Traxer et al. 2011
J Endourol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

26. SPIES No studies in UTUC Baard et al. 2017 Nat Rev Urol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

27. PDD with oral 5-ALA 26 biopsies
11 visible under both white and blue light: 100% malignant
10 visible only under blue light – 70% malignant
5 random biopsies of normal mucosa – 100% benign
Ahmad et al. 2012
BJU Int
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

28. OCT
26 patients
In 83% staging was in accordance with final histopathology (RNU or SU)
For tumour invasion: sensitivity of 100% and specificity of 92%
Bus et al. 2016
J Urol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

29. CLE Ongoing studies for UTUC Bui et al. 2015 J Endourol
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas

30. Take-home message
In imperative cases conservative management should be offered to patients.
Patients with low-risk disease should be offered (as a default) endoscopic management with laser ablation as an option.
To date, this statement relies mainly on low level evidence; further clinical research is absolutely mandatory.
Meticulous and stringent follow-up is a key component of low-risk disease, with the potential for numerous repeat scans or endoscopic procedures.
Patients with high-risk disease should by default proceed to early RNU.
Endoscopic Treatment of Upper Tract Urothelial Tumours
Vítor Cavadas