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. 2023 Jun;131(6):755-762.
doi: 10.1111/bju.15945. Epub 2023 Jan 23.

Diagnostic evaluation of upper tract urothelial carcinoma: can we safely omit diagnostic ureteroscopy?

Matthew Trail  1 , Muhammad Sajid Waheed Rahman  2 , William J Broadhurst  2 , James P Blackmur  1   3 , Abhishek Sharma  1 , Etienne Chew  2 , Marie O'Donnell  4 , Julian Y Keanie  5 , John Brush  5 , John Taylor  5 , Simon Phipps  1 , Ben Thomas  1 , Edward A A Mains  1 , S Alan McNeill  1   2 , Steve Leung  1 , Mark L Cutress  1 , Alexander Laird  1   3
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Diagnostic evaluation of upper tract urothelial carcinoma: can we safely omit diagnostic ureteroscopy?

Matthew Trail et al. BJU Int. 2023 Jun.

Abstract

Objective: To identify clinicopathological or radiological factors that may predict a diagnosis of upper urinary tract urothelial cell carcinoma (UTUC) to inform which patients can proceed directly to radical nephroureterectomy (RNU) without the delay for diagnostic ureteroscopy (URS).

Patients and methods: All consecutive patients investigated for suspected UTUC in a high-volume UK centre between 2011 and 2017 were identified through retrospective analysis of surgical logbooks and a prospectively maintained pathology database. Details on clinical presentation, radiological findings, and URS/RNU histopathology results were evaluated. Multivariate regression analysis was performed to evaluate predictors of a final diagnosis of UTUC.

Results: In all, 260 patients were investigated, of whom 230 (89.2%) underwent URS. RNU was performed in 131 patients (50.4%), of whom 25 (9.6%) proceeded directly without URS - all of whom had a final histopathological diagnosis of UTUC - and 15 (11.5%) underwent RNU after URS despite no conclusive histopathological confirmation of UTUC. Major surgery was avoided in 77 patients (33.5%) where a benign or alternative diagnosis was made on URS, and 14 patients (6.1%) underwent nephron-sparing surgery. Overall, 178 patients (68.5%) had a final diagnosis of UTUC confirmed on URS/RNU histopathology. On multivariate logistic regression analysis, a presenting complaint of visible haematuria (hazard ratio [HR] 5.17, confidence interval [CI] 1.91-14.0; P = 0.001), a solid lesion reported on imaging (HR 37.8, CI = 11.7-122.1; P < 0.001) and a history of smoking (HR 3.07, CI 1.35-6.97; P = 0.007), were predictive of a final diagnosis of UTUC. From this cohort, 51 (96.2%) of 53 smokers who presented with visible haematuria and who had a solid lesion on computed tomography urogram had UTUC on final histopathology.

Conclusion: We identified specific factors which may assist clinicians in selecting which patients may reliably proceed to RNU without the delay of diagnostic URS. These findings may inform a prospective multicentre analysis including additional variables such as urinary cytology.

Keywords: #uroonc; #utuc; CT urography; UTUC; UUTUC; diagnosis; diagnostic ureteroscopy; pathway; upper urinary tract urothelial cell carcinoma.

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References

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