JOURNAL OF ENDOUROLOGY Volume 28, Number 8, August 2014 ª Mary Ann Liebert, Inc. Pp. 922–925 DOI: 10.1089/end.2013.0703
Routine Diagnostic Ureteroscopy for Suspected Upper Tract Transitional-Cell Carcinoma Alexander Tsivian, MD,1 Matvey Tsivian, MD,2 Yury Stanevsky, MD,1 Eli Tavdy, MD,1 and A. Ami Sidi, MD1
Abstract
Background and Purpose: Upper tract transitional-cell carcinoma (utTCC) is uncommon. Standard evaluation includes imaging, cytology, and cystoscopy and gold standard treatment is nephroureterectomy (NU) with solid oncologic outcomes and elevated morbidity. In this study, we report on the value of including routine ureteroscopy (URS) for evaluating suspected utTCC in shifting the treatment toward less morbid options and increasing preoperative diagnostic accuracy. Patients and Methods: Records of patients presenting between 2002 and 2013 with suspected utTCC were reviewed. Since 2010, URS has been included routinely in the evaluation protocol. Demographic, clinical, and pathologic characteristics were recorded and compared between earlier experience (group 1) and with routine URS (group 2). In addition, the number needed to treat (NNT) was calculated with respect to shifting the procedure choice from NU to other options as well as in reducing the rates of misdiagnoses. Results: A total of 118 patients were included: 63 in group 1 and 55 in group 2. The pathology-confirmed TCC rates were comparable between the two groups (78 vs 85%). The rates of NU decreased with routine URS use from 89% to 69% (P = 0.011, NNT = 5.05) whereby patients were treated endoscopically or with distal ureterectomy. Misdiagnoses decreased from 15.5% to 2.1% with routine URS (P = 0.021, NNT = 7.44). Sepsis occurred in two patients after URS. Conclusions: In this initial study, routine URS evaluation for suspected utTCC appears to enable an increased use of other treatment choices rather then NU, with an estimated five URS avoiding one NU. Moreover, routine URS reduced the rates of misdiagnosis of TCC. Complications associated with URS may add an additional morbidity burden, however.
Introduction
U
pper tract transitional-cell carcinoma (utTCC) is relatively uncommon, but its incidence has been on the rise in the past decades and it represents today about 7% of all kidney cancers.1 Nephroureterectomy (NU) with ipsilateral bladder cuff excision remains the gold standard treatment for utTCC regardless of tumor location, whereas in selected patients, endoscopic treatment may be appropriate.2 NU has been shown to offer good oncologic outcomes; however, morbidity and mortality are considerable, even in centers of excellence.3,4 In addition, the impact of NU on renal function is substantial, and new onset of chronic kidney disease after NU in not uncommon.5,6 Population-based studies indicate that NU may have almost 2% 30-day and as
high as 4.4% 90-day mortality rates.7,8 The majority of deaths occurred because of renal insufficiency and cardiovascular disease.8 It is well known that several other pathologies, both malignant and benign, can mimic utTCC on imaging studies,9–11 but the extent of misdiagnoses is not known. Current indications for NU include suspicion of infiltrating utTCC on imaging and high-grade tumor cells on urinary cytologic evaluation. Cytology, however, has less than optimal sensitivity, particularly for utTCC. Ureteroscopy (URS) is a valuable diagnostic tool that allows for better determination of the extent of the lesion as well as tissue sampling that may aid in determining whether a nephron-sparing approach can be used. To date, the routine application of diagnostic URS in the evaluation of suspected
1 Department of Urologic Surgery, E. Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. 2 Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
922
UPPER TRACT TCC
utTCC is debated with conflicting and low-grade evidence to support either view.12,13 At our institution, since 2010, URS has been incorporated into the routine practice when evaluating patients with suspected utTCC based on imaging, cytology, and cystoscopy. In this study, we compare our experience with and without routine URS evaluation in the setting of suspected utTCC. We assess the value of URS in helping establish the correct diagnosis preoperatively and evaluate the ability of routine URS to shift the procedure choice from NU to less morbid treatment options. Patients and Methods
After approval form the Institutional Review Board, records of patients undergoing evaluation for suspected utTCC at our institution between 2002 and 2013 were reviewed. Demographic, clinical, radiographic, and pathologic data were retrieved. The patients were then divided into two groups based on our changed clinical practice patterns. Since 2010, diagnostic URS has been incorporated into the evaluation protocol for patients with suspected utTCC along with physical examination, laboratory studies, urine cytology, and imaging (CT and retrograde pyelography). Before 2010, URS was used in selected cases. Demographic, clinical, and pathologic characteristics were summarized for this cohort and compared between the groups. Patient management strategies were summarized and compared between the groups to assess changes in the management plans with routine use of URS. NU was considered the baseline option, and any other procedure was considered a change in patient management. In a subset of patients with suspected TCC after complete workup, the rates of misdiagnosis were compared based on implementation of URS in the evaluation. Number needed to treat (NNT) was calculated to estimate the impact of URS on management strategies and correct diagnosis. Statistical analyses were performed using R software version 3.0 with Hmisc, gmodels, and epicalc packages (The R Foundation for Statistical Computing, Vienna, Austria). All tests were two-sided; P values
Routine Diagnostic Ureteroscopy for Suspected Upper Tract Transitional-Cell Carcinoma Alexander Tsivian, MD,1 Matvey Tsivian, MD,2 Yury Stanevsky, MD,1 Eli Tavdy, MD,1 and A. Ami Sidi, MD1
Abstract
Background and Purpose: Upper tract transitional-cell carcinoma (utTCC) is uncommon. Standard evaluation includes imaging, cytology, and cystoscopy and gold standard treatment is nephroureterectomy (NU) with solid oncologic outcomes and elevated morbidity. In this study, we report on the value of including routine ureteroscopy (URS) for evaluating suspected utTCC in shifting the treatment toward less morbid options and increasing preoperative diagnostic accuracy. Patients and Methods: Records of patients presenting between 2002 and 2013 with suspected utTCC were reviewed. Since 2010, URS has been included routinely in the evaluation protocol. Demographic, clinical, and pathologic characteristics were recorded and compared between earlier experience (group 1) and with routine URS (group 2). In addition, the number needed to treat (NNT) was calculated with respect to shifting the procedure choice from NU to other options as well as in reducing the rates of misdiagnoses. Results: A total of 118 patients were included: 63 in group 1 and 55 in group 2. The pathology-confirmed TCC rates were comparable between the two groups (78 vs 85%). The rates of NU decreased with routine URS use from 89% to 69% (P = 0.011, NNT = 5.05) whereby patients were treated endoscopically or with distal ureterectomy. Misdiagnoses decreased from 15.5% to 2.1% with routine URS (P = 0.021, NNT = 7.44). Sepsis occurred in two patients after URS. Conclusions: In this initial study, routine URS evaluation for suspected utTCC appears to enable an increased use of other treatment choices rather then NU, with an estimated five URS avoiding one NU. Moreover, routine URS reduced the rates of misdiagnosis of TCC. Complications associated with URS may add an additional morbidity burden, however.
Introduction
U
pper tract transitional-cell carcinoma (utTCC) is relatively uncommon, but its incidence has been on the rise in the past decades and it represents today about 7% of all kidney cancers.1 Nephroureterectomy (NU) with ipsilateral bladder cuff excision remains the gold standard treatment for utTCC regardless of tumor location, whereas in selected patients, endoscopic treatment may be appropriate.2 NU has been shown to offer good oncologic outcomes; however, morbidity and mortality are considerable, even in centers of excellence.3,4 In addition, the impact of NU on renal function is substantial, and new onset of chronic kidney disease after NU in not uncommon.5,6 Population-based studies indicate that NU may have almost 2% 30-day and as
high as 4.4% 90-day mortality rates.7,8 The majority of deaths occurred because of renal insufficiency and cardiovascular disease.8 It is well known that several other pathologies, both malignant and benign, can mimic utTCC on imaging studies,9–11 but the extent of misdiagnoses is not known. Current indications for NU include suspicion of infiltrating utTCC on imaging and high-grade tumor cells on urinary cytologic evaluation. Cytology, however, has less than optimal sensitivity, particularly for utTCC. Ureteroscopy (URS) is a valuable diagnostic tool that allows for better determination of the extent of the lesion as well as tissue sampling that may aid in determining whether a nephron-sparing approach can be used. To date, the routine application of diagnostic URS in the evaluation of suspected
1 Department of Urologic Surgery, E. Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. 2 Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
922
UPPER TRACT TCC
utTCC is debated with conflicting and low-grade evidence to support either view.12,13 At our institution, since 2010, URS has been incorporated into the routine practice when evaluating patients with suspected utTCC based on imaging, cytology, and cystoscopy. In this study, we compare our experience with and without routine URS evaluation in the setting of suspected utTCC. We assess the value of URS in helping establish the correct diagnosis preoperatively and evaluate the ability of routine URS to shift the procedure choice from NU to less morbid treatment options. Patients and Methods
After approval form the Institutional Review Board, records of patients undergoing evaluation for suspected utTCC at our institution between 2002 and 2013 were reviewed. Demographic, clinical, radiographic, and pathologic data were retrieved. The patients were then divided into two groups based on our changed clinical practice patterns. Since 2010, diagnostic URS has been incorporated into the evaluation protocol for patients with suspected utTCC along with physical examination, laboratory studies, urine cytology, and imaging (CT and retrograde pyelography). Before 2010, URS was used in selected cases. Demographic, clinical, and pathologic characteristics were summarized for this cohort and compared between the groups. Patient management strategies were summarized and compared between the groups to assess changes in the management plans with routine use of URS. NU was considered the baseline option, and any other procedure was considered a change in patient management. In a subset of patients with suspected TCC after complete workup, the rates of misdiagnosis were compared based on implementation of URS in the evaluation. Number needed to treat (NNT) was calculated to estimate the impact of URS on management strategies and correct diagnosis. Statistical analyses were performed using R software version 3.0 with Hmisc, gmodels, and epicalc packages (The R Foundation for Statistical Computing, Vienna, Austria). All tests were two-sided; P values
