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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. Confirm Diagnosis prior to Nephroureterectomy 10.2% - Benign disease
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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 • Confirm Diagnosis prior to Nephroureterectomy • 10.2% - Benign disease • Increasing pressure for nephron sparing endoscopic approaches • Solitary kidney, bilateral tumours, renal impairment • High surgical risk patient • Low grade low stage tumours • Traditionally difficult to assess upper tract stage with imaging • Ureteroscopic biopsies – accurate? • 75% accurate in predicting upper-tract TCC grade • 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 • Evaluate • Indications for referral • Accuracy of ureteroscopy in staging upper-tract TCC • Ureteroscopic findings • Upper-tract urine cytology • Ureteroscopic biopsy • Correlate with Final surgical histology
Study Cohort • 85 patients • 55M : 30F • Average age 68 yrs (range 28-98) • 75 Routine diagnostic • 10 Complex diagnostic • conduit / distal ureterectomy / horseshoe kidney
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 3 patients Awaiting Nephroureterectomy 18 patients Nephroureterectomy 45 patients Discharged Back to referring clinician 15 patients Endoscopic Management 4 patients Declined treatment Palliative Care
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 • Failure to investigate endoscopically may result in unnecessary procedures for benign disease • Filling defects on prior imaging - No TCC demonstrated in 66% cases • Ureteroscopically - if it looks like TCC – it usually is • Upper-tract urine cytology helps identify high grade disease • Ureteroscopic biopsy is not always accurate - but can predict high grade disease • The combination of ureteroscopic appearance, cytology and biopsy • will diagnose upper-tract TCC • may help identify patients not suitable for conservative therapy