Ureteroscopy Is Indicated in

every patient with suspected

Upper Tract Urothelial Tumor

Scott G. Hubosky, MD The Demetrius H. Bagley Jr., MD Associate Professor of Urology

Director of Endourology

Vice Chair of Quality and Safety

Thomas Jefferson University Hospital

Philadelphia, PA, USA

DISCLOSURES

• I HAVE NO FINANCIAL INTERESTS OR RELATIONSHIPS TO

DISCLOSE

MULTIPLE FILLING DEFECTS AND

GROSS HEMATURIA!

Ureteral Filling Defect with Gross Hematuria and

Flank Pain!!!

FIBROEPITHELIAL POLYPS

FIBROEPITHELIAL POLYPS

Benign Pathology Found after

Laparoscopic Radical NU

• 7/244 (2.9%) found to have Benign Pathology (Presumed UTUC)

• 5 did not have URS evaluation

• 2 incomplete URS evaluation (unable to access pathology)

• 5 with Ureteral Lesions CT Finding • Polypoid ureteritis / ureteral stone PeriUreteral Wall Thickening

• Urothelial hyperplasia / ureteral stone Enhancing Ureteral Soft Tissue Mass

• Inflammatory Pseudotumor 1.5 cm Enhancing Mass in Mid Ureter

• Submucosal Hemorrhage Enhancing Mass Distal Ureter

• TB Multifocal Ureteral Wall Thickening

• 2 with Renal Pelvic Lesions • Inflammatory Pseudotumor 4cm Enhancing UTUC renal pelvis

• Fibroepithelial Polyp 1.6 cm Enhancing mass renal pelvis

Hong et al 2014 JSLS (18) 1-17

Potretzke et al 2016 Urology (88) 43-8

What is the best treatment choice?

Reasons NOT to do Ureteroscopy in UTUC

• Increased Pyelovenous Backflow = Local Tumor Spread or

Promotion of Metastatic Disease / Cancer Specific Mortality

• Delays time to definitive Surgery (NU)

• Leads to Bladder Tumor Development

• URS does not really add anything

Does Flexible Ureteroscopy Promote Local

Recurrence of Upper Tract Urothelial Carcinoma?

• ? Migration of malignant cells from Increased Intrarenal Pressure?

• Evaluated 13 patients who had URS prior to ultimate NU (all with UTUC)

• Surgical (NU) specimens examined for vascular/lymphatic invasion

• No Tumor cells seen in Vascular/Lymphatic spaces

• No tumor seen outside of or penetrating renal capsule

• Direct extension of tumor into renal parenchyma (1)

• Suspected prior to URS being performed

• Patients followed with CT (mean 34 months)

• Only one patient with eventual metastatic disease

Kulp & Bagley 1994 J Endourol (8) 111-3

Impact of Diagnostic Ureteroscopy on Long-Term

Survival in UTUC patients after NU

• Retrospective review of 48

patients in each group.

• Demographics statistically

equivalent including preop grade

• Mean follow up (42-50 months)

• Rate of Metastatic Disease same

• 12% URS group

• 19% Control group

• Overall Survival same (p=0.75)

• 87% URS group

• 76% Control group

Hendin et al 1999 J Urol (161) 783-5

What does URS do in terms of bladder tumor

development in those without prior BT hx?

• Sankin et al

• Median follow-up of 5.4 years

• Intravesical Recurrence Rate (IRR) higher in those with URS (58% vs. 29%)

• No difference in Cancer Specific Survival

• Luo et al

• Mean follow-up 40.7 months

• IRR higher in those with URS (40.9% vs. 27.8%)

• No difference in Metastasis Free Survival and Cancer Specific Survival

• Ishikawa et al

• Median follow-up 44 months

• IRR similar: With URS 60%, Without URS 58.7%

• No difference in Cancer Specific Survival

1. Sankin et al 2016 Urology (94) 148-53

2. Luo et al 2013 Ann Surg Oncol DOI 10.1245/s10434-013-3000-z

3. Ishikawa et al 2010 J Urol (184) 883-7

MD ANDERSON: Higher Stage UTUC

“The treatment paradigm needed to change”

• Surgical Series of NU from 1986 – 2004 (N = 184) • Group 1 N = 42

1986-1994

• Group 2 N = 50 1995-1999

• Group 3 N = 92 2000-2004

• No difference in DSS among 3 groups over 20 years!!!

• Pts with high risk features continued to do poorly

Brown et al. BJUI 2006 (98) 1176-80

REDUCTION IN ELIGIBLE PATIENTS FOR

CISPLATIN-BASED CHEMO AFTER NU

• Multi-institutional Retrospective

Review of NU patients for UTUC

• Mean age 70 yrs (62 – 76)

• If cutoff for cisplatin-based

chemotherapy is GFR > 60

• 49% eligible PREOP

• 19% eligible POSTOP

• Strengthened the argument for

Neoadjuvant Chemotherapy

Kaag et al. Eur Urol 2010 (58) 581-7

Porten et al 2014 Cancer (120) 1794-9

Porten et al 2014 Cancer (120) 1794-9

Observations

• The stakes are getting

higher for UTUC treatment

• NEOADJUVANT

CHEMOTHERAPY

• Better Options for Nephron

Sparing Therapies

• Endoscopic Treatments

• MITOGEL

• Local Bladder recurrences

are increased modestly

• Post-op MMC after URS?