Photodynamic diagnosis in upper urinary tract urothelial carcinoma: A systematic review

Abstract

Objective: To assess the diagnostic accuracy and safety of photodynamic diagnosis (PDD) in upper urinary tract urothelial carcinoma (UUTUC).

Materials and methods: A systematic literature search was conducted. Included studies were assessed for the risks of bias and quality using appropriate tools. Dedicated data extraction forms were used. Diagnostic accuracy in terms of sensitivity and specificity were quoted whenever provided by individual studies. A combined toxicity profile of 5-aminolevulinic acid (5ALA) was given after reviewing individual studies.

Results: In all, 17 studies were identified. After screening seven studies were included involving a total of 194 patients. None of the studies were randomised. All the available studies were of low-to-moderate quality. The largest available study, with 106 patients, reported a sensitivity of 95.8% and 53.5% for PDD and white-light (WL) ureterorenoscopy (URS) respectively, with a statistically significant difference. The specificity was 96.6% for PDD and 95.2% for WL-URS with no statistical significance. PDD showed better ability in detecting carcinoma in situ and dysplasia. One study compared PDD to computed tomography urogram (CTU) and found PDD to have better sensitivity and statistically significantly better specificity. 5ALA-associated toxicity was minor in nature and hypotension was the most common adverse event.

Conclusion: PDD in UUTUC appears to be more accurate than WL-URS and CTU, with no significant toxicity. Larger scale randomised trials are needed.

Keywords: (UUT)UC, (upper urinary tract) urothelial carcinoma; 5-Aminolaevulinic; 5ALA, 5-aminolevulinic acid; Blue light detection; CIS, carcinoma in situ; CTU, CT urogram; HAL, hexaminolaevulinate; HNPCC, non-polyposis colorectal carcinoma; NBI, narrow-band imaging; PDD, photodynamic diagnosis; PPIX, protoporphyrin IX; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; Photodynamic diagnosis; Photodynamic ureteroscopy; QUADAS, Quality Assessment of Diagnostic Accuracy Studies; URS, ureterorenoscopy; Upper tract TCC; WL, white-light.

Fig. 1

PRISMA flow diagram for PDD in UUTUC .

Fig. 2

Distribution of the adverse events associated with 5ALA.