Transcript Endoscopic diagnosis of TCC – Correlating indications

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
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Confirm Diagnosis prior to Nephroureterectomy
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10.2% - Benign disease
Increasing pressure for nephron sparing endoscopic approaches
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Solitary kidney, bilateral tumours, renal impairment
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High surgical risk patient
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Low grade low stage tumours
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Traditionally difficult to assess upper tract stage with imaging
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Ureteroscopic biopsies – accurate?
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75% accurate in predicting upper-tract TCC grade
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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;157:1560-56
Study Aims
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Evaluate
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Indications for referral
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Accuracy of ureteroscopy in staging upper-tract TCC
 Ureteroscopic findings
 Upper-tract urine cytology
 Ureteroscopic biopsy
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Correlate with Final surgical histology
Study Cohort
85 patients
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55M : 30F
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Average age 68 yrs (range 28-98)
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75 Routine diagnostic
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10 Complex diagnostic
 conduit / distal ureterectomy / horseshoe kidney
Referral pattern 2004 - 2010
25
20
Cases per year

15
10
5
0
2004
2005
2006
2007
2008
2009
2010
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
15 patients
Endoscopic
Management
3 patients
Awaiting
Nephroureterectomy
4 patients
Declined treatment
Palliative Care
45 patients
Discharged
Back to referring
clinician
Ureteroscopic findings and final histology
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%
Uretero-ileal anastamosis – 4%
TCC not visualised – 5%
• Stricture
• Tortuous upper ureter
When TCC seen endoscopically
ALL final histology confirmed TCC
Upper-tract cytology and Pathological grade
Pathological
grade
Ureteroscopic biopsy grade and Pathological
grade
Pathological
grade
Ureteroscopic biopsy grade and Pathological
stage
Pathological
stage
Positive endoscopic investigations and Surgical
grade
Pathological
stage
Conclusions
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Failure to investigate endoscopically may result in unnecessary procedures for benign
disease
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Filling defects on prior imaging - No TCC demonstrated in 66% cases
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Ureteroscopically - if it looks like TCC – it usually is
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Upper-tract urine cytology helps identify high grade disease
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Ureteroscopic biopsy is not always accurate - but can predict high grade disease
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The combination of ureteroscopic appearance, cytology and biopsy
1.
will diagnose upper-tract TCC
2.
may help identify patients not suitable for conservative therapy