Ureteroscopy Is Indicated in every patient with suspected Upper Tract Urothelial Tumor Scott G. Hubosky, MD The Demetrius H. Bagley Jr., MD Associate Professor of Urology Director of Endourology Vice Chair of Quality and Safety Thomas Jefferson University Hospital Philadelphia, PA, USA
DISCLOSURES • I HAVE NO FINANCIAL INTERESTS OR RELATIONSHIPS TO DISCLOSE
MULTIPLE FILLING DEFECTS AND GROSS HEMATURIA!
Ureteral Filling Defect with Gross Hematuria and Flank Pain!!!
FIBROEPITHELIAL POLYPS
FIBROEPITHELIAL POLYPS
Benign Pathology Found after Laparoscopic Radical NU • 7/244 (2.9%) found to have Benign Pathology (Presumed UTUC) • 5 did not have URS evaluation • 2 incomplete URS evaluation (unable to access pathology) • 5 with Ureteral Lesions CT Finding • Polypoid ureteritis / ureteral stone PeriUreteral Wall Thickening • Urothelial hyperplasia / ureteral stone Enhancing Ureteral Soft Tissue Mass • Inflammatory Pseudotumor 1.5 cm Enhancing Mass in Mid Ureter • Submucosal Hemorrhage Enhancing Mass Distal Ureter • TB Multifocal Ureteral Wall Thickening • 2 with Renal Pelvic Lesions • Inflammatory Pseudotumor 4cm Enhancing UTUC renal pelvis • Fibroepithelial Polyp 1.6 cm Enhancing mass renal pelvis Hong et al 2014 JSLS (18) 1-17
Potretzke et al 2016 Urology (88) 43-8
What is the best treatment choice?
Reasons NOT to do Ureteroscopy in UTUC • Increased Pyelovenous Backflow = Local Tumor Spread or Promotion of Metastatic Disease / Cancer Specific Mortality • Delays time to definitive Surgery (NU) • Leads to Bladder Tumor Development • URS does not really add anything
Does Flexible Ureteroscopy Promote Local Recurrence of Upper Tract Urothelial Carcinoma? • ? Migration of malignant cells from Increased Intrarenal Pressure? • Evaluated 13 patients who had URS prior to ultimate NU (all with UTUC) • Surgical (NU) specimens examined for vascular/lymphatic invasion • No Tumor cells seen in Vascular/Lymphatic spaces • No tumor seen outside of or penetrating renal capsule • Direct extension of tumor into renal parenchyma (1) • Suspected prior to URS being performed • Patients followed with CT (mean 34 months) • Only one patient with eventual metastatic disease Kulp & Bagley 1994 J Endourol (8) 111-3
Impact of Diagnostic Ureteroscopy on Long-Term Survival in UTUC patients after NU • Retrospective review of 48 patients in each group. • Demographics statistically equivalent including preop grade • Mean follow up (42-50 months) • Rate of Metastatic Disease same • 12% URS group • 19% Control group • Overall Survival same (p=0.75) • 87% URS group • 76% Control group Hendin et al 1999 J Urol (161) 783-5
What does URS do in terms of bladder tumor development in those without prior BT hx? • Sankin et al • Median follow-up of 5.4 years • Intravesical Recurrence Rate (IRR) higher in those with URS (58% vs. 29%) • No difference in Cancer Specific Survival • Luo et al • Mean follow-up 40.7 months • IRR higher in those with URS (40.9% vs. 27.8%) • No difference in Metastasis Free Survival and Cancer Specific Survival • Ishikawa et al • Median follow-up 44 months • IRR similar: With URS 60%, Without URS 58.7% • No difference in Cancer Specific Survival 1. Sankin et al 2016 Urology (94) 148-53 2. Luo et al 2013 Ann Surg Oncol DOI 10.1245/s10434-013-3000-z 3. Ishikawa et al 2010 J Urol (184) 883-7
MD ANDERSON: Higher Stage UTUC “The treatment paradigm needed to change” • Surgical Series of NU from 1986 – 2004 (N = 184) • Group 1 N = 42 1986-1994 • Group 2 N = 50 1995-1999 • Group 3 N = 92 2000-2004 • No difference in DSS among 3 groups over 20 years!!! • Pts with high risk features continued to do poorly Brown et al. BJUI 2006 (98) 1176-80
REDUCTION IN ELIGIBLE PATIENTS FOR CISPLATIN-BASED CHEMO AFTER NU • Multi-institutional Retrospective Review of NU patients for UTUC • Mean age 70 yrs (62 – 76) • If cutoff for cisplatin-based chemotherapy is GFR > 60 • 49% eligible PREOP • 19% eligible POSTOP • Strengthened the argument for Neoadjuvant Chemotherapy Kaag et al. Eur Urol 2010 (58) 581-7
Porten et al 2014 Cancer (120) 1794-9
Porten et al 2014 Cancer (120) 1794-9
Observations • The stakes are getting higher for UTUC treatment • NEOADJUVANT CHEMOTHERAPY • Better Options for Nephron Sparing Therapies • Endoscopic Treatments • MITOGEL • Local Bladder recurrences are increased modestly • Post-op MMC after URS?
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