Diagnostic ureteroscopy for upper tract urothelial carcinoma: friend or foe?

ABSTRACT

INTRODUCTION: The European Association of Urology guidelines recommend offering kidney-sparing surgery (KSS) as a primary treatment option to patients with low-risk tumours. Cystoscopy, urinary cytology, and computed tomography urography (CTU) do not always allow correct disease staging and grading, and sometimes there is even a lack of certainty regarding the diagnosis of UTUC. Diagnostic ureteroscopy (d-URS) may therefore be of crucial importance within the diagnostic framework and fundamental in establishing the appropriate therapeutic approach. EVIDENCE ACQUISITION AND SYNTHESIS: A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of interventions (ROBINS-I). Overall, from 3791 identified records, 186 full-text articles were assessed for eligibility. Finally, after a quantitative review of the selected literature, with the full agreement of all authors, 62 studies were considered relevant for this review. RESULTS: CTU has a sensitivity and specificity for UTUC of 92% and 95% respectively, but is not able to detect small or flat lesions with adequate accuracy. The sensitivity of voided urinary cytology for UTUC is around 67-76% and ranges from 43% to 78% for selective ureteric urine collection. As no technique offers a diagnosis of certainty, d-URS can allow an increase in diagnostic accuracy. In the present review the pros and cons of d-URS were analysed. This technique may provide additional information in the selection of patients suitable for neoadjuvant chemotherapy or KSS, distinguishing between normal tissue and low- and high-grade UTUC thanks to the emerging technologies. CONCLUSIONS: Information obtainable from d-URS and ureteroscopic-guided biopsy can prove extremely valuable when the diagnosis of UTUC is doubtful or KSS is being considered. Notwithstanding concerns remain regarding the potential risk of bladder recurrence, cancer dissemination, and/or delay in radical treatment.Abbreviations CLE confocal laser endomicroscopy; CSS cancer-specific survival; CTU CT urography; d-URS diagnostic ureteroscopy; EAU European Association of Urology; HR hazard ratio; IMAGE1S Storz professional imaging enhancement system; IVR intravesical recurrence; KSS kidney-sparing surgery; MFS Metastasis-free survival; NAC neoadjuvant chemotherapy; NBI narrow-band imaging; OCT optical coherence tomography; RFS Recurrence-free survival; RNU radical nephroureterectomy; ROBINS-I Risk of Bias in Non-randomized Studies of interventions; URS(-GB) Ureteroscopy(-guided biopsy); UTUC upper tract urothelial carcinoma; UUT upper urinary tract.