Development and validation of a clinical and ultrasound features-based nomogram for preoperative differentiation of renal urothelial carcinoma and central renal cell carcinoma.

PURPOSE: This study aimed to develop and validate an ultrasound (US)-based nomogram for the preoperative differentiation of renal urothelial carcinoma (rUC) from central renal cell carcinoma (c-RCC). METHODS: Clinical data and US images of 655 patients with 655 histologically confirmed malignant renal tumors (521 c-RCCs and 134 rUCs) were collected and divided into training (n = 455) and validation (n = 200) cohorts according to examination dates. Conventional US and contrast-enhanced US (CEUS) tumor features were analyzed to determine those that could discriminate rUC from c-RCC. Least absolute shrinkage and selection operator regression was applied to screen clinical and US features for the differentiation of rUC from c-RCC. Using multivariate logistic regression analysis, a diagnostic model of rUC was constructed and visualized as a nomogram. The diagnostic model's performance was assessed in the training and validation cohorts by calculating the area under the receiver operating characteristic curve (AUC) and calibration plot. Decision curve analysis (DCA) was used to assess the clinical usefulness of the US-based nomogram. RESULTS: Seven features of both clinical features and ultrasound imaging were selected to build the diagnostic model. The nomogram achieved favorable discrimination in the training (AUC = 0.996, 95% CI: 0.993-0.999) and validation (AUC = 0.995, 95% CI: 0.974, 1.000) cohorts, and good calibration (Brier scores: 0.019 and 0.016, respectively). DCA demonstrated the clinical usefulness of the US-based nomogram. CONCLUSION: A noninvasive clinical and US-based nomogram combining conventional US and CEUS features possesses good predictive value for differentiating rUC from c-RCC.

Imaging of Upper Tract Urothelial Carcinoma.

Upper tract urothelial carcinoma (UTUC) originates in the renal pelvis or ureters and typically affects elderly patients, with its incidence increasing over the past few decades. UTUC is a distinct clinical entity with more aggressive clinical behavior than that of lower tract urothelial carcinoma. Due to the significant challenge of acquiring an adequate tissue sample for biopsy, comprehensive risk stratification is required for treatment planning, including radical nephroureterectomy and kidney-sparing management. Imaging plays an important integrated role in risk assessment along with endoscopy and pathologic examination. Lifelong surveillance is required after treatment due to the high incidence of recurrent and metachronous tumors. Lynch syndrome is a frequently unrecognized genetic disorder associated with UTUC that warrants specific attention in patient management. UTUC may manifest with diverse imaging findings, including filling defects, wall thickening, and mass-forming lesions. CT urography is the preferred modality for diagnosis and staging or restaging of UTUC, with numerous technical variations. Efforts have been made to optimize image quality and radiation exposure. Due to its poor sensitivity for small lesions, use of MR urography is limited to special clinical scenarios (eg, when patients have contraindications to iodinated contrast agents). Fluorine 18 fluorodeoxyglucose PET helps to detect metastatic lesions. Image-guided biopsy may be considered for uncertain lesions. Radiologists need to be familiar with the imaging findings and their differential diagnoses. ©RSNA, 2024 Supplemental material is available for this article.

Practical Guide to VI-RADS: MRI Protocols, Lesion Characterization, and Pitfalls.

Urothelial carcinoma is the most common type of bladder cancer (BC), accounting for approximately 90% of all cases. Evaluating the depth of tumor invasion in the bladder wall (tumor staging) is essential for determining the treatment and prognosis in patients with BC. Neoadjuvant therapy followed by radical cystectomy is the most common treatment of localized muscle-invasive BC (MIBC). Therefore, it is vital to differentiate non-MIBC from MIBC. Transurethral resection of bladder tumor (TURBT) is the reference standard to determine the extent of tumor invasion into the bladder wall through tissue sampling. However, this diagnostic and therapeutic method may not adequately sample the muscularis propria, leading to a higher risk of residual disease, early recurrence, and tumor understaging in approximately 50% of patients during the initial TURBT. Multiparametric MRI can overcome some of the limitations of TURBT when evaluating BC, particularly regarding tumor staging. In this context, the Vesical Imaging Reporting and Data System (VI-RADS) classification was developed to establish standards for bladder multiparametric MRI and interpretation. It uses a 5-point scale to assess the likelihood of detrusor muscle invasion. T2-weighted MR images are particularly useful as an initial guide, especially for categories 1-3, while the presence of muscular invasion is determined with diffusion-weighted and dynamic contrast-enhanced sequences. Diffusion-weighted imaging takes precedence as the dominant method when optimal image quality is achieved. The presence of a stalk or a thickened inner layer and no evidence of interruption of the signal intensity of the muscular layer are central for predicting a low likelihood of muscle invasion. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Hoegger in this issue.

CT findings and clinical characteristics in distinguishing renal urothelial carcinoma mimicking renal cell carcinoma from clear cell renal cell carcinoma.

BACKGROUND: We aimed to characterize the clinical and multiphase computed tomography (CT) features, which can distinguish renal urothelial carcinoma (RUC) mimicking renal cell carcinoma (RCC) from clear cell renal cell carcinoma (ccRCC) with collecting system invasion (CSI). METHODS: Data from 56 patients with RUC (46 men and 10 women) and 366 patients with ccRCC (262 men and 104 women) were collected and assessed retrospectively. The median age was 65.50 (IQR: 56.25-69.75) and 53.50 (IQR: 42.25-62.5) years, respectively. Univariate and multivariate logistic regression analyses were performed on clinical and CT characteristics to determine independent factors for distinguishing RUC and ccRCC, and an integrated predictive model was constructed. Differential diagnostic performance was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: The independent predictors for differentiating RUC from ccRCC were infiltrative growth pattern, hydronephrosis, heterogeneous enhancement, preserving reniform contour, and hematuria. The differential diagnostic performance of the integrated predictive model-1 (AUC: 0.947, sensitivity: 89.07%, specificity: 89.29%) and model-2 (AUC: 0.960, sensitivity: 92.1%, specificity: 89.3%) were both better than that of the infiltrative growth pattern (AUC: 0.830, sensitivity: 71.9%, specificity: 92.9%), heterogeneous enhancement (AUC: 0.771, sensitivity: 86.3%, specificity: 67.9%), preserving reniform contour (AUC = 0.758, sensitivity: 85.5%, specificity: 66.1%), hydronephrosis (AUC: 0.733, sensitivity: 87.7%, specificity: 58.9%), or hematuria (AUC: 0.706, sensitivity: 79.5%, specificity: 51.8%). CONCLUSION: The CT and clinical characteristics showed extraordinary discriminative abilities in the differential diagnosis of RUC and ccRCC, which might provide helpful information for clinical decision-making.

Application of contrast-enhanced ultrasound in diagnosis and grading of bladder urothelial carcinoma.

PURPOSE: To explore the application of contrast-enhanced ultrasound (CEUS) for the diagnosis and grading of bladder urothelial carcinoma (BUC). METHODS: The results of a two-dimensional ultrasound, color Doppler ultrasound and CEUS, were analyzed in 173 bladder lesion cases. The ultrasound and surgical pathology results were compared, and their diagnostic efficacy was analyzed. RESULTS: There were statistically significant differences between BUC and benign lesions in terms of color blood flow distribution intensity and CEUS enhancement intensity (both P < 0.05). The area under the time-intensity curve (AUC), rising slope, and peak intensity of BUC were significantly higher than those of benign lesions (all P < 0.05). The H/T (height H / basal width T)value of 0.63 was the critical value for distinguishing high- and low-grade BUC, had a diagnostic sensitivity of 80.0% and a specificity of 60.0%. CONCLUSION: The combination of CEUS and TIC can help improve the diagnostic accuracy of BUC. There is a statistically significant difference between high- and low-grade BUC in contrast enhancement intensity (P < 0.05); The decrease of H/T value indicates the possible increase of the BUC grade.

Both radiographical and pathological lymph node statuses are independent predictors for survival following neoadjuvant chemotherapy and radical cystectomy for cT3/4 or cN+ bladder cancer.

INTRODUCTION: Urothelial bladder cancer (UBC) with clinical suspicion of locally advanced growth or pelvic lymphogenic spread has a high risk of progression and death. PATIENTS AND METHODS: Bladder cancer patients with locally advanced (cT3/4) tumor growth or suspected pelvic lymphogenic spread (cN+) were treated with preoperative cisplatin-containing chemotherapy and consolidative cystectomy with pelvic lymphadenectomy. We aimed to identify prognostic factors and describe the patients' oncological outcome. RESULTS: A complete dataset including follow-up data was available for 96 patients. In a univariate analysis, we identified cN stage (cN+ vs cN-, HR 2.7, 95% CI 1.3-6.0), response to chemotherapy (HR 0.2, 95% CI 0.1-0.5), ypT stage (ypT0/is/1 vs ypT2-4, HR 3.1, 95% CI 1.4-6.8), ypN stage (ypN + vs ypN-, HR 7.9, 95% CI 3.7-17.0), resection status (HR 4.4, 95% CI HR 1.5-13.0) as significantly associated with cancer-specific survival. In a multivariate regression analysis, both cN and ypN statuses were validated as independent prognostic factors for cancer-specific survival (cN: HR 2.6, 95% CI 1.1-6.1; ypN: HR 5.5, 95% CI 2.0-15.1). DISCUSSION: Lymph node status was identified as a prognostic marker in a high-risk cohort of UBC patients treated with inductive chemotherapy and cystectomy. Establishing cN status as a prognosticator underlines the necessity to aggressively treat these patients despite reported impreciseness of imaging procedures in UCB. Patients with histologically positive lymph nodes following preoperative chemotherapy have a very poor prognosis, and thus, the need for adjuvant systemic treatment is emphasized. CONCLUSION: Both clinically and pathologically affected lymph nodes convey a poor prognosis in bladder cancer and necessitate aggressive treatment.

Current methods facilitating diagnosis of upper tract urothelial carcinoma: a comprehensive literature review.

PURPOSE OF REVIEW: Currently, kidney-sparing surgeries are considered the preferred approach in low-risk tumours and in selected high-risk patients. Therefore, accurate diagnosis of UTUC is crucial for further management. The purpose of this review is to summarize available methods facilitating the diagnosis of upper tract urothelial carcinoma (UTUC). RECENT FINDINGS: Recent articles propose numerous techniques of UTUC diagnosis. In this review, imaging, as well as, urine-based and endoscopic methods have been described and assessed. SUMMARY: Regarding imaging, computed tomography urography remains a gold standard, while PET is superior in search for small lesions and nodal metastases. However, contrast-enhanced ultrasonography also shows promise. On the contrary, available urine tests, such as urinary cytology, fluorescent in-situ hybridization, Xpert, DNA methylation analysis, urine-based liquid biopsy, p16/Ki-67 dual immunolabelling, ImmunoCyt and NMP22 are either poorly researched, or not accurate enough to use solely. Finally, during ureterorenoscopy, photodynamic diagnosis and narrow-band imaging can facilitate proper visualization of the tumor. Endoluminal ultrasonography and confocal laser endomicroscopy can potentially improve staging and grading of UTUC. Also, the 'form tackle' biopsy should be performed using a basket in papillary lesions and cold-cup biopsy of flat or sessile lesions. Even though cryobiopsy shows promise in UTUC diagnosis, in-vivo studies are necessary before it is introduced into clinical practice.

Primary high-grade urothelial carcinoma of prostate with prostatic hyperplasia: a rare case report and review of the literature.

BACKGROUND: Primary urothelial carcinoma in the prostate (UCP) is extremely rare and occurs most frequently in the bladder. There are only dozens of primary cases reported in the literature. Here, we describe a rare case of primary UCP and review the literature. CASE PRESENTATION: A 67-year-old widowed male, was referred to our hospital due to the frequency, and urgency of dysuria. Magnetic resonance imaging (MRI) examination revealed prostate size was about 57 mm × 50 mm × 54 mm, increased prostatic transitional zone, and surrounding of prostatic duct indicate bar isointense T1, short T2, hyperintense DWI, and hyposignal ADC (PI-RADS 3); posterior of peripheral zone indicate patchy isointense T1, short T2, hyperintense DWI, and hyposignal ADC (PI-RADS 5). Subsequently, the patient underwent a transrectal prostate biopsy. Histopathological and immunohistochemical (IHC) assessments showed prostatic high-grade urothelial carcinoma with benign prostatic hyperplasia. Finally, the patient underwent laparoscopic radical prostatectomy. Four months after surgery, CT plain and enhanced scan revealed thickening of the bladder wall. On further workup, cystoscopy revealed lymphoid follicular changes in the cut edge of the radical prostatectomy, and cystoscopic biopsies showed the malignant tumor. CONCLUSIONS: Prostatic urothelial carcinoma should always be considered if the patient with severe lower urinary tract symptoms or hematuria, PSA, and digital rectal examination without abnormalities, without a personal history of urothelial cancer, but contrast-enhanced MRI showed the lesion located in the prostate. As of right now, radical surgical resections remain the most effective treatment. The effectiveness of neoadjuvant or adjuvant chemotherapy is still controversial.

Lymph Node Dissection in Upper Tract Urothelial Carcinoma: Current Status and Future Perspectives.

PURPOSE OF REVIEW: This narrative review aims to evaluate the role of lymph node dissection (LND) in upper tract urothelial carcinoma (UTUC) and its implications for staging and management outcomes, as well as future perspectives. RECENT FINDINGS: Multiple studies have demonstrated the limitations of conventional imaging techniques in accurately localizing lymph node metastasis (LNM) in UTUC. While 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18FDG-PET/CT) shows promise for preoperative LNM detection, its specificity is low. Alternative methods such as choline PET/CT and sentinel lymph node detection are under consideration but require further investigation. Additionally, various preoperative factors associated with LNM hold potential for predicting nodal involvement, thereby improving nodal staging and oncologic outcomes of LND. Several surgical approaches, including segmental ureterectomy and robot-assisted nephroureterectomy, provide a possibility for LND, while minimizing morbidity. LND remains the primary nodal staging tool for UTUC, but its therapeutic benefit is still uncertain. Advances in imaging techniques and preoperative risk assessment show promise in improving LNM detection. Further research and multi-center studies are needed to comprehensively assess the advantages and limitations of LND in UTUC, as well as the long-term outcomes of alternative staging and treatment strategies.

Adherence to guideline recommendations in the management of upper tract urothelial carcinoma: an analysis of the CROES-UTUC registry.

BACKGROUND: The European Association of Urology provides Clinical Practice Guideline on upper tract urothelial carcinoma (UTUC). Due to the rarity of UTUC, guidelines are necessary to help guide decision-making based on the highest quality of care evidence available. OBJECTIVES: To evaluate guideline adherence in the management of UTUC by assessing recommendations on diagnostics needed for risk classification and subsequent treatment selection; to assess predictors for the latter. PARTICIPANTS: Data from the Clinical Research Office of the Endo Urology Society UTUC-registry were included for analysis. STATISTICAL ANALYSIS: Overall compliance were evaluated by cross-tables, differences in risk groups characteristics and treatment selection were assessed by Chi-square tests, predictors for treatment selection by logistic regression analysis. RESULTS: Data from 2380 patients were included. Imaging by CT-scan had highest adherence (85%) but was low for other diagnostics (17.7-49.7%). Multivariable regression analysis showed higher odds of receiving radical nephroureterectomy in patients with large tumours (OR 5.45, 95% CI 3.77-7.87, p < 0.001), signs of invasion (OR 3.07,CI 2.11-4.46, p < 0.001), high tumour grade (OR 2.05, CI 1.38-3.05, p < 0.001) and multifocality (OR 1.76,CI 1.05-2.97, p =0.032). CONCLUSIONS: CT-imaging is the most used and most impactful decision tool for risk-stratification and treatment selection in UTUC. Due to the low compliance in most of the diagnostic recommendations, proper risk stratification is not possible in a significant group of patients raising the question whether current stratification is deemed applicable in daily practice. Established prognostic factors on survival guides decision-making regarding radical versus kidney-sparing surgery. Tumour size was the most influencing factor on treatment decision. CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (ClinicalTrials.gov NCT02281188; https://clinicaltrials.gov/ct2/show/NCT02281188 ).

Evaluation of a fractional-order calculus diffusion model and bi-parametric VI-RADS for staging and grading bladder urothelial carcinoma.

OBJECTIVES: To evaluate the feasibility of high b-value diffusion-weighted imaging (DWI) for distinguishing non-muscle-invasive bladder cancer (NMIBC) from muscle-invasive bladder cancer (MIBC) and low- from high-grade bladder urothelial carcinoma using a fractional-order calculus (FROC) model as well as a combination of FROC DWI and bi-parametric Vesical Imaging-Reporting and Data System (VI-RADS). METHODS: Fifty-eight participants with bladder urothelial carcinoma were included in this IRB-approved prospective study. Diffusion-weighted images, acquired with 16 b-values (0-3600 s/mm2), were analyzed using the FROC model. Three FROC parameters, D, ß, and µ, were used for delineating NMIBC from MIBC and for tumor grading. A receiver operating characteristic (ROC) analysis was performed based on the individual FROC parameters and their combinations, followed by comparisons with apparent diffusion coefficient (ADC) and bi-parametric VI-RADS based on T2-weighted images and DWI. RESULTS: D and µ were significantly lower in the MIBC group than in the NMIBC group (p = 0.001 for each), and D, ß, and µ all exhibited significantly lower values in the high- than in the low-grade tumors (p ≤ 0.011). The combination of D, ß, and µ produced the highest specificity (85%), accuracy (78%), and the area under the ROC curve (AUC, 0.782) for distinguishing NMIBC and MIBC, and the best sensitivity (89%), specificity (86%), accuracy (88%), and AUC (0.892) for tumor grading, all of which outperformed the ADC. The combination of FROC parameters with bi-parametric VI-RADS improved the AUC from 0.859 to 0.931. CONCLUSIONS: High b-value DWI with a FROC model is useful in distinguishing NMIBC from MIBC and grading bladder tumors. KEY POINTS: • Diffusion parameters derived from a FROC diffusion model may differentiate NMIBC from MIBC and low- from high-grade bladder urothelial carcinomas. • Under the condition of a moderate sample size, higher AUCs were achieved by the FROC parameters D (0.842) and µ (0.857) than ADC (0.804) for bladder tumor grading with p ≤ 0.046. • The combination of the three diffusion parameters from the FROC model can improve the specificity over ADC (85% versus 67%, p = 0.031) for distinguishing NMIBC and MIBC and enhance the performance of bi-parametric VI-RADS.

The use of MRI in urothelial carcinoma.

PURPOSE OF REVIEW: To conduct a nonsystematic review of the existing literature to investigate the role of Magnetic Resonance Imaging (MRI) in urothelial carcinomas (UCs). RECENT FINDINGS: Imaging is becoming progressively more crucial in local and distant staging of UCs, especially in cases of bladder cancer (BCa). The primary objective of imaging in patients with BCa is to detect lesions and distinguish T1 from T2 stages, since the treatment varies significantly. SUMMARY: The applicability of MRI in the management of UCs has been investigated, particularly focusing on the new evidence on multiparametric MRI (mpMRI) of the bladder and Vesical Imaging-Reporting And Data System score for the description of BCa and discussing the possible utility of MRI for upper tract urothelial carcinomas . Imaging modalities, in particular CT and MRI, are essential tools for the local and distant staging of UCs. MpMRI of the bladder and VI-RADS score accurately define the risk of muscle invasiveness, promoting tailored therapeutic planning. Moreover, mpMRI has also been included in patients' follow-up and in the assessment of response to systematic therapy. MRI utility and possible application in upper tract urothelial carcinomas cases are yet to be discovered.

EUS-guided fine needle aspiration provides an open view for duodenal obstruction caused by urothelial carcinoma: a case report.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a good alternative and diagnostic tool for gastrointestinal wall thickening with prior negative endoscopic biopsies. CASE PRESENTATION: Here we reported a case of a 60-years-old woman admitted with atrophic right kidney and hydronephrosis and intermittent postprandial bloating. Esophagogastroduodenoscopy and small bowel endoscopy revealed wall thickening and stenosis at the junction of the descending and inferior duodenum. Biopsies from endoscopy showed no specific findings. EUS-FNA of the thickened duodenal wall was performed and histopathological examinations revealed poorly differentiated carcinoma. Immunohistochemically staining was positive for pan-cytokeratin, CK7, CK20, and weakly positive for GATA-3 and P63. These results were highly suggestive of metastatic urothelial cancer. CONCLUSIONS: EUS-FNA played an important role in the diagnosis of unexplained gastrointestinal wall thickening and rare metastases to the gastrointestinal wall.

Ultrasonographic detection of apex nodules in the urinary bladder of Scottish Terriers.

An apex nodule was recently identified in the urinary bladder of Scottish Terriers being screened for bladder cancer at our institution. This prospective, single-center, case series study was performed to better characterize the apex nodule and assess the clinical importance of the nodule. Scottish Terriers ≥6 years of age with no evidence of urinary tract disease underwent urinary tract ultrasonography and urinalysis at 6-month intervals. In dogs with evidence of the apex nodule, ultrasound features such as location, margins, number, echogenicity, size, and shape of the lesion were recorded by a veterinary oncologist and veterinary radiologist. The apex nodule was identified in eight (6%) of 134 dogs in the absence of other detectable bladder disease. Features of the nodules included the following: one nodule per dog, triangular to an oval shape, smooth mucosal covering, well-defined margins, isoechoic to the bladder wall, 2-4 mm at the base, and 4-6 mm protruding into the bladder lumen. In five dogs undergoing multiple ultrasonographic examinations, the nodule did not appear to change over time (up to 3.5 years). Cystoscopy performed in three dogs revealed a column of tissue covered by normal mucosa protruding into the bladder lumen. Histological features consistent with a neoplastic growth were absent. Five dogs remained free of any bladder disease. Three dogs developed urothelial carcinoma at sites distant to the nodule at 8-53 months after the nodule was first observed. Findings indicated that incidental apex nodules could mimic neoplasia and other bladder diseases in Scottish Terriers.

Acute inflammatory presentation of orbital metastasis from urothelial carcinoma: a case report.

Orbital metastasis of urothelial carcinoma is very rare; only 22 cases have been documented. In this case report, we describe a patient 1 month status post transurethral resection of urothelial carcinoma who presented with a clinical picture suggestive of orbital cellulitis. However, neither broad-spectrum antibiotics nor a subsequent trial of methylprednisolone was effective at relieving the patient's symptoms. CT imaging of the head, chest, abdomen, pelvis, and lower extremity showed no signs of metastatic disease. Six days after presentation, punch biopsy of the mass was performed and confirmed urothelial carcinoma metastatic to the orbit. The patient died 3 months later due to multiple sites of distant metastasis. This case report suggests that a high index of suspicion for orbital metastasis is important for patients with a history of urothelial carcinoma with new and acute onset of ocular symptoms and emphasizes the need for urgent systemic evaluation and treatment.

Prospective Validation of Vesical Imaging-Reporting and Data System Using a Next-Generation Magnetic Resonance Imaging Scanner-Is Denoising Deep Learning Reconstruction Useful?

PURPOSE: The Vesical Imaging Reporting and Data System (VI-RADS) was launched in 2018 to standardize reporting of magnetic resonance imaging for bladder cancer. This study aimed to prospectively validate VI-RADS using a next-generation magnetic resonance imaging scanner and to investigate the usefulness of denoising deep learning reconstruction. MATERIALS AND METHODS: We prospectively enrolled 98 patients who underwent bladder multiparametric magnetic resonance imaging using a next-generation magnetic resonance imaging scanner before transurethral resection of bladder tumor. Tumors were categorized according to VI-RADS, and we ultimately analyzed 68 patients with pathologically confirmed urothelial bladder cancer. We used receiving operating characteristic curve analyses to assess the predictive accuracy of VI-RADS for muscle invasion. Sensitivity, specificity, positive/negative predictive value, accuracy and area under the curve were calculated for different VI-RADS score cutoffs. RESULTS: Muscle invasion was detected in the transurethral resection of bladder tumor specimens of 18 patients (26%). The optimal cutoff value of the VI-RADS score was determined as ≥4 based on the receiver operating curve analyses. The accuracy of diagnosing muscle invasion using a cutoff of VI-RADS ≥4 was 94% (AUC 0.92). Additionally, we assessed the utility of denoising deep learning reconstruction. Combination with denoising deep learning reconstruction significantly improved the AUC of category by T2-weighted imaging, and of the 4 patients who were misdiagnosed by the final VI-RADS score 3 were correctly diagnosed by T2-weighted imaging+denoising deep learning reconstruction. CONCLUSIONS: In this prospective validation study with a next-generation magnetic resonance imaging scanner, VI-RADS showed high predictive accuracy for muscle invasion in patients with bladder cancer before transurethral resection of bladder tumor. Combining T2-weighted imaging with denoising deep learning reconstruction might further improve the diagnostic accuracy of VI-RADS.

The Impact of Ureteroscopy following Computerized Tomography Urography in the Management of Upper Tract Urothelial Carcinoma.

PURPOSE: We report the reliability of computerized tomography urography and ureteroscopy in the diagnosis and management of upper tract urothelial carcinoma. MATERIALS AND METHODS: From 2015 to November 2018 we prospectively collected and retrospectively analyzed 244 cases of ureteroscopy with available preoperative computerized tomography urography. Computerized tomography urography was categorized as positive, suspicious, unlikely and negative. Correspondence between imaging, ureteroscopy and histology was analyzed. The therapeutic indication, based on 2020 EAU Guidelines and patient clinical data, was recorded before and after ureteroscopy. Cohen's Kappa was used for agreement analysis. Logistic regression was used for prediction of positive ureteroscopy. RESULTS: Ureteroscopy was positive for upper tract urothelial carcinoma in 107/115 (93%), 48/77 (62.3%), 15/27 (55.6%) and 12/25 (48%) cases with positive, suspicious, unlikely and negative computerized tomography urography, respectively. On cytohistology the result was confirmed in 164/182 (90.1%) cases. The positive predictive value of a filling defect, stenosis, thickening and hydronephrosis on computerized tomography urography was 87.7% (121/138 cases), 65.6% (21/32), 69.6% (64/92) and 79.7% (59/74), respectively. On multivariate analysis a filling defect (95% CI 2.76-11.5, OR 5.63, p <0.0001) or hydronephrosis (1.04-6.18, OR 2.52, p=0.04) was associated with ureteroscopy outcome. Among cases with positive computerized tomography urography and ureteroscopy, the lesions differed in dimensions (20/107), number (14/107) and site (11/107), for a total of 45/107 (42.1%) cases. The indication of elective treatment changed after ureteroscopy in 37/76 (48.1%) cases (Kappa=0.31), as 17/28 (60.7%), 11/20 (55%) and 11/28 (39.2%) indications were confirmed for endoscopic management, ureterectomy and nephroureterectomy, respectively. CONCLUSIONS: The complementary use of computerized tomography urography and ureteroscopy in the diagnostic workup of upper tract urothelial carcinoma should be evaluated.

Prediction of pathological response following neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer: the PRE-PREVENCYS trial.

BACKGROUND: The recommended treatment for patients with non-metastatic muscle-invasive bladder cancer (MIBC) is neoadjuvant chemotherapy (NAC) and radical cystectomy (RC). Following NAC, 20-40% of patients experience a complete pathological response (pCR) in the RC specimen and these patients have excellent long-term overall survival. Subject to debate is, however, whether patients with a pCR to NAC benefit from RC, which is a major surgical procedure with substantial morbidity, and if these patients might be candidates for close surveillance instead. However, currently it is not possible to accurately identify patients with a pCR to NAC in whom RC might be withheld. The objective of this study is to assess whether pathological response in the RC specimen after NAC can be predicted based on clinical, radiological, and histological variables and on a wide set of molecular biomarkers assessed in tissue, blood and urine. METHODS: This is a multicentre, prospective cohort study, including patients with cT2a-T4a N0-N1 M0 urothelial cell MIBC who are scheduled to undergo cisplatin-based NAC followed by RC. Prior to start of therapy, a 2-Deoxy-2-[18F] fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) is performed. Response to NAC is evaluated by CT-scan. Blood and urine, including cytology, are prospectively collected for biomarker analyses before and after NAC. Immediately before RC, participants undergo cystoscopy with bimanual examination and a re-staging transurethral resection (TUR) of all visible cancerous lesions or with biopsies from scar tissue. Subsequently, RC is performed in all patients. Tissue from the diagnostic TUR, the re-staging TUR, and the RC specimen is examined for the presence of urothelial cancer carcinoma and DNA and RNA is isolated for molecular analysis. The primary endpoint is the pathological stage (ypTN) in the RC and ePLND specimen and its association with clinical response. DISCUSSION: If the PRE-PREVENCYS trial shows that the absence of residual disease after NAC in patients with MIBC is accurately predicted, a randomized controlled trial is scheduled comparing the overall survival of NAC plus RC versus NAC followed by close surveillance for patients with a clinically complete response (PREVENCYS trial). TRIAL REGISTRATION: Netherlands Trial Register: NL8678; Registered 20 May 2020 https://www.trialregister.nl/trial/8678.

Flexible fibre optic vs digital ureteroscopy and enhanced vs unenhanced imaging for diagnosis and treatment of upper tract urothelial carcinoma (UTUC): results from the Clinical Research Office of the Endourology Society (CROES)-UTUC registry.

OBJECTIVES: To compare the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing kidney-sparing surgery (KSS) with fibre-optic (FO) vs digital (D) ureteroscopy (URS). To evaluate the oncological impact of image-enhancement technologies such as narrow-band imaging (NBI) and Image1-S in patients with UTUC. PATIENTS AND METHODS: The Clinical Research Office of the Endourology Society (CROES)-UTUC registry is an international, multicentre, cohort study prospectively collecting data on patients with UTUC. Patients undergoing flexible FO- or D-URS for diagnostic or diagnostic and treatment purposes were included. Differences between groups in terms of overall survival (OS) and disease-free survival (DFS) were evaluated. RESULTS: The CROES registry included 2380 patients from 101 centres and 37 countries, of whom 401 patients underwent URS (FO-URS 186 and D-URS 215). FO-URS were performed more frequently for diagnostic purposes, while D-URS was peformed when a combined diagnostic and treatment strategy was planned. Intra- and postoperative complications did not differ between the groups. The 5-year OS and DFS rates were 91.5% and 66.4%, respectively. The mean OS was 42 months for patients receiving FO-URS and 39 months for those undergoing D-URS (P = 0.9); the mean DFS was 28 months in the FO-URS group and 21 months in the D-URS group (P < 0.001). In patients who received URS with treatment purposes, there were no differences in OS (P = 0.9) and DFS (P = 0.7). NBI and Image1-S technologies did not improve OS or DFS over D-URS. CONCLUSIONS: D-URS did not provide any oncological advantage over FO-URS. Similarly, no differences in terms of OS and DFS were found when image-enhancement technologies were compared to D-URS. These findings underline the importance of surgeon skills and experience, and reinforce the need for the centralisation of UTUC care.

Contemporary patterns of presentation, diagnostics and management of upper tract urothelial cancer in 101 centres: the Clinical Research Office of the Endourological Society Global upper tract urothelial carcinoma registry.

PURPOSE OF REVIEW: To assess patterns of presentation, diagnostics and treatment in patients with upper tract urothelial carcinoma (UTUC), a multicentre registry was launched. Clinical data of UTUC patients were prospectively collected over a 5-year period. RECENT FINDINGS: Data from 2380 patients were included from 2014 to 2019 (101 centres in 29 countries). Patients were predominantly male (70.5%) and 53.3% were past or present smokers. The majority of patients (58.1%) were evaluated because of symptoms, mainly macroscopic hematuria. Computed tomography (CT) was the most common performed imaging modality (90.5%). A ureteroscopy (URS) was part of the diagnostic process in 1184 (49.7%) patients and 488 (20.5%) patients were treated endoscopically. In total, 1430 patients (60.1%) were treated by a radical nephroureterectomy, 59% without a prior diagnostic URS. Eighty-two patients (3.4%) underwent a segmental resection, 19 patients (0.8%) were treated by a percutaneous tumour resection. SUMMARY: Our data is in line with the known epidemiologic characteristics of UTUC. CT imaging is the preferred imaging modality as also recommended by guidelines. Diagnostic URS gained a stronger position, however, in almost half of patients a definitive treatment decision was made without complete endoscopic information. Only one-third of patients with UTUC are currently treated with kidney sparing surgery.