Ureteroscopic biopsy of upper tract urothelial carcinoma and role of urinary biomarkers

Ureteroscopic biopsy is an integral part of diagnosis of urothelial carcinoma of the upper urinary tract. It can be a technical challenge, but diagnostic rates have improved remarkably with refinements in surgical technique and specimen processing. Cytology aids with diagnosis and other urinary biomarkers continue to evolve, which may help further stratify patients for treatment. The current literature on the ureteroscopic biopsy and role of urinary biomarkers is reviewed and summarized below

The significance of functional renal obstruction in predicting pathologic stage of upper tract urothelial carcinoma.

BACKGROUND AND PURPOSE: Assessing the severity of upper tract urothelial carcinoma (UTUC) has been difficult because of inadequate biopsy specimens. Additional predictive parameters of disease stage would be useful when deciding a treatment plan; it has been suggested that preoperative hydronephrosis can be a surrogate. We examined the relationship between preoperative ipsilateral renal obstruction identified by imaging with final pathologic stage after nephroureterectomy (NU) for UTUC. We then analyzed those patients with ipsilateral renal obstruction and examined if tumor location is associated with an advanced pathologic stage. METHODS: Patients who underwent NU for UTUC between the years 2001 to 2013 were analyzed and relevant staging studies and pathology were reviewed. Criteria for ipsilateral renal obstruction were defined by the presence of a delayed nephrogram on CT scan, renal cortical atrophy with associated hydronephrosis on cross-sectional imaging, and/or \u3e10% split function discrepancy on nuclear renal scintigraphy with associated hydronephrosis. RESULTS: Eighty-two patients met inclusion criteria; 26/82 (31.7%) had locally advanced disease (pT3/T4), while 56/82 (63.4%) had organ-confined (≤pT2) disease. Of the patients with pT3/T4 disease, 10/26 (38.5%) demonstrated radiographic evidence of functional obstruction of the ipsilateral renal unit; similarly, in patients with ≤pT2 disease, 21/56 (37.5%) demonstrated ipsilateral renal obstruction (P=0.93). Of the patients with ipsilateral renal obstruction, in those patients with pT3/T4 disease, 7/10 (70.0%) had ureteral tumor involvement while 9/21 (42.9%) patients with ≤pT2 disease had tumor in the ureter (P=0.25). CONCLUSIONS: This study suggests that renal obstruction by radiographic analysis does not always predict advanced stage. In addition, there is a trend toward advanced stage when a patient has radiographic evidence of ipsilateral renal dysfunction and a ureteral tumor

The Minimally Invasive Management of Ureteropelvic Junction Obstruction in Horseshoe Kidneys

Purpose: Data regarding the treatment of ureteropelvic junction obstruction (UPJO) in horseshoe kidneys are limited. We performed a retrospective analysis of our experience with minimally invasive treatment of UPJO in patients with this anomaly. Methods: Between March of 1996 and March 2008, 9 patients with horseshoe kidneys were treated for UPJO at our institution. Of these patients, 6 were managed with retrograde endopyelotomy, 2 with laparoscopic pyeloplasty, and one by robotic pyeloplasty. Outcomes of these procedures were retrospectively reviewed. Results: A total of nine patients were available for analysis. Four of six patients who underwent endopyelotomy had available follow-up, with a mean of 56 months. The success rate for these patients was 75%. Two of three patients (67%) in the laparoscopic/robotic cohort were successfully treated with a mean follow-up of 21 months. Conclusions: UPJO in horseshoe kidneys can pose a therapeutic dilemma. The minimally invasive treatment of these patients is feasible with good success rates for both endopyelotomy and laparoscopic/robotic pyeloplast

Bad Out of the Box: A Report on Pre-operative Failure Rates of Reusable Flexible Ureteroscopes at a Single Institution

Purpose: Single-use flexible ureteroscopes offer the advantage of being consistently functional and perfect for immediate clinical use right “out of the box.” Cost is the barrier to widespread acceptance of these instruments. Economic models have been put forth which compare the expense of acquiring and maintaining reusable flexible ureteroscopes to that of using single-use flexible ureteroscopes.However, one poorly defined variable in these models is the frequency of encountering an unsuitable reusable flexible ureteroscope at the beginning of a case. We sought to define this in a consecutive series of patients undergoing flexible ureteroscopy. Patients and Methods: Prospective analysis of all consecutive cases requiring flexible ureteroscopy over three months was undertaken. A combination of fiberoptic and digital flexible ureteroscopes comprised the available inventory. Per protocol, these instruments were grossly cleaned in the endourology suite after use, and sent to central processing for final cleaning, sterilization (STERRAD) and packaging. Repairs were managed by a third party repair service when needed. Ureteroscopes were defined as acceptable if they provided reasonable visualization, deflection, an open working channel that would accept passage of instruments and no evidence of gross contamination or overt damage/deformity. Results: Of 228 consecutive cases, a total of 261 reusable flexible ureteroscopes were unwrapped and 93 (90%) cases were initiated with the first instrument opened. In 11 (9.0%) cases, the initial ureteroscope opened was unacceptable for use and required opening an additional ureteroscope(s). In 7 cases, at least 2 instruments were opened. Also, 3,4, and 5 instruments needed to be opened in 1 case each. One case had to be rescheduled after 4 consecutive instruments were opened and all were unsuitable. Of 17 unfit instruments, 19 problems were noted and included broken deflection (4), dried cleaning solution on the instrument tip (4), inability to pass a laser fiber through the working channel (5), digital camera dislodged from distal bending rubber (2), crushed proximal shaft (1), digital image failure (1), lens trouble causing optical failure (1) and a missing sterilization cap (1). Considering all 119 instruments opened, 17 (14%) were unsuitable for immediate use. Conclusions: In up to 12.6% of cases, the initially opened reusable flexible ureteroscope is not fit for initiation of the procedure. This rate may vary among institutions depending on repair, processing, and nursing practices but represents one area where single use devices can fill an essential and immediate role.https://jdc.jefferson.edu/patientsafetyposters/1091/thumbnail.jp