Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma: Oncologic Outcomes and Prognostic Factors in a Contemporary Cohort

The incidence and classification of intraoperative adverse events in urological surgery: a systematic review

PURPOSE

To perform a systematic review (SR) to examine the application of classification systems (CS) used to report intraoperative adverse events (iAEs) in urological surgery and to evaluate the crude incidence and type of iAEs.

MATERIALS AND METHODS

This review was published via PROSPERO (CRD42024549954) and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). MEDLINE, Embase, and the Cochrane CENTRAL were searched using a predefined PICO framework: (P) patients with benign and malignant urological diseases, (I) all types of urological surgery, (C) none/any, (O) intraoperative complications classified with grading systems. Retrospective and prospective studies published between January 2019 and June 2024 were included.

RESULTS

The search yielded 1,570 abstracts, 1,043 full-text articles were assessed for eligibility, of which 325 studies reported iAEs (54 used iAE-CS, 64 used Clavien-Dindo Classification and 207 used free-text descriptions). Of the 54 studies (15,298 patients) that used an iAE-CS, the three most used systems were the EAUiaiC (54%), SATAVA (26%), and the modified SATAVA (7%). The overall incidence of iAE was 14% (2,153/15,225 patients). On a study level, the crude incidence of iAE was between 0 and 100% (median 7%, IQR: 3-13%). The misapplication of the Clavien-Dindo system to describe iAEs was high (n = 64 studies).

CONCLUSIONS

The use of iAE-CS is scarce, and there is a lack of universal consensus on a CS to describe iAEs. iAE are poorly reported in urological studies. Urologists should report all perioperative complications to improve transparency and surgical and hospital processes.

Oncologic Outcomes of Endoscopic Management of Upper Tract Urothelial Carcinoma: A Systematic Review and Pooled Analysis from the EAU-YAU Urothelial Working Group

BACKGROUND AND OBJECTIVE

Data about the mid- and long-term oncologic outcomes of endoscopic kidney-sparing surgery (eKSS) for upper tract urothelial carcinoma (UTUC) are scarce. Therefore, we aimed to summarize the current evidence on the oncologic outcomes of eKSS for UTUC.

METHODS

A literature search was conducted to identify reports published until May 2024. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The outcomes were the following: recurrence-free (RFS), intravesical recurrence-free (IV-RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival.

KEY FINDINGS AND LIMITATIONS

We found 56 studies (n = 52 retrospective) that met our inclusion criteria (n = 2862 patients). The 1-, 2-, 5-, and 10-yr OS rates were 96%, 87%, 80%, and 42%, respectively. The 1-, 2-, 5-, and 10-yr CSS rates were 97%, 89%, 82%, and 69%, respectively. RFS rates at 1, 2, and 5 yr were 69%, 55%, and 45%, respectively. IV-RFS rates at 1, 2, and 5 yr were 80%, 65%, and 64%, respectively. PFS rates at 2 and 5 yr were 75% and 69%, respectively. In low-grade UTUC, OS rates at 2 and 5 yr were 93% and 77%, respectively. The 2- and 5-yr CSS rates were 98% and 88%, respectively. At 2 yr, RFS, IV-RFS, and PFS were 52%, 54%, and 94%, respectively. For high-grade UTUC, only three studies reported data on 2-yr RFS, which was 34%. The main limitation is the heterogeneity found across the studies.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Local recurrence, bladder recurrence, and progression of UTUC occur mainly within 2 yr after eKSS. After 5-yr follow-up, OS and CSS drop, while the risk of local recurrence is non-negligible.

Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma

OBJECTIVE

To assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI).

MATERIALS AND METHODS

Single center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications.

RESULTS

Overall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR.

CONCLUSIONS

Complications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

First analysis of the safety and efficacy of UGN-101 in the treatment of ureteral tumors

OBJECTIVE

UGN-101 has been approved for the chemoablation of low-grade upper tract urothelial cancer (UTUC) involving the renal pelvis and calyces. Herein is the first reported cohort of patients with ureteral tumors treated with UGN-101.

PATIENTS AND METHODS

We performed a retrospective review of patients treated with UGN-101 for UTUC at 15 high-volume academic and community centers focusing on outcomes of patients treated for ureteral disease. Patients received UGN-101 with either adjuvant or chemo-ablative intent. Response rates are reported for patients receiving chemo-ablative intent. Adverse outcomes were characterized with a focus on the rate of ureteral stenosis.

RESULTS

In a cohort of 132 patients and 136 renal units, 47 cases had tumor involvement of the ureter, with 12 cases of ureteral tumor only (8.8%) and 35 cases of ureteral plus renal pelvic tumors (25.7%). Of the 23 patients with ureteral involvement who received UGN-101 induction with chemo-ablative intent, the complete response was 47.8%, which did not differ significantly from outcomes in patients without ureteral involvement. Fourteen patients (37.8%) with ureteral tumors had significant ureteral stenosis at first post-treatment evaluation, however, when excluding those with pre-existing hydronephrosis or ureteral stenosis, only 5.4% of patients developed new clinically significant stenosis.

CONCLUSIONS

UGN-101 appears to be safe and may have similar efficacy in treating low-grade urothelial carcinoma of the ureter as compared to renal pelvic tumors.

Current Evidence on Utility, Outcomes, and Limitations of Endoscopic Laser Ablation for Localized Upper Urinary Tract Urothelial Carcinoma: Results from a Scoping Review

Context

The occurrence of upper urinary tract urothelial carcinoma (UTUC) is uncommon and is usually identified at an advanced and multifocal stage. Currently, there is growing interest in utilizing endoscopic laser ablation (ELA).

Objective

To evaluate the survival rates and perioperative complications of ELA.

Evidence acquisition

We performed a literature search through PubMed, Web of Science, and Scopus. The analysis included observational studies that examined the oncological outcomes of patients with UTUC treated with ELA.

Evidence synthesis

Neodymium and diode lasers are no longer used due to their high complication rates. Holmium:yttrium-aluminum-garnet (YAG) and thulium:YAG lasers provided excellent tumor ablation and hemostasis in both the collecting system and the ureter. These lasers offer good disease-free and cancer-specific survival, especially for low-grade tumors.

Conclusions

Advancements in laser technology and ablation techniques, and understanding of UTUC tumor biology hold significant promise in improving the use of conservative UTUC treatment, with excellent safety and good oncological outcomes for low-grade diseases.

Patient summary

With the advancement of technology, the conservative approach utilizing endoscopic laser ablation for upper tract urothelial tumors has been proved to be both safe and effective, showcasing promising survival rates.

Fluorescence Confocal Microscopy in Urological Malignancies: Current Applications and Future Perspectives

Fluorescence confocal microscopy (FCM) represents a novel diagnostic technique able to provide real-time histological images from non-fixed specimens. As a consequence of its recent developments, FCM is gaining growing popularity in urological practice. Nevertheless, evidence is still sparse, and, at the moment, its applications are heterogeneous. We performed a narrative review of the current literature on this topic. Papers were selected from the Pubmed, Embase, and Medline archives. We focused on FCM applications in prostate cancer (PCa), urothelial carcinoma (UC), and renal cell carcinoma (RCC). Articles investigating both office and intraoperative settings were included. The review of the literature showed that FCM displays promising accuracy as compared to conventional histopathology. These results represent significant steps along the path of FCM's formal validation as an innovative ready-to-use diagnostic support in urological practice. Instant access to a reliable histological evaluation may indeed significantly influence physicians' decision-making process. In this regard, FCM addresses this still unmet clinical need and introduces intriguing perspectives into future diagnostic pathways. Further studies are required to thoroughly assess the whole potential of this technique.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training Research in Urological Surgery and Technology (T.R.U.S.T.) group

PURPOSE

To highlight and compare experts' laser settings during endoscopic laser treatment of upper tract urothelial carcinoma (UTUC), to identify measures to reduce complications, and to propose guidance for endourologists.

METHODS

Following a focused literature search to identify relevant questions, a survey was sent to laser experts. We asked participants for typical settings during specific scenarios (ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and percutaneous treatment). These settings were compared among the reported laser types to find common settings and limits. Additionally, we identified preventive measures commonly applied during surgery.

RESULTS

Twenty experts completed the survey, needing a mean time of 12.7 min. Overall, most common laser type was Holmium-Yttrium-Aluminum-Garnet (Ho:YAG) (70%, 14/20) followed by Thulium fiber laser (TFL) (45%, 9/20), pulsed Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) (3/20, 15%), and continuous wave (cw)Tm:YAG (1/20, 5%). Pulse energy for the treatment of distal ureteral tumors was significantly different with median settings of 0.9 J, 1 J and 0.45 J for Ho:YAG, TFL and pulsed Tm:YAG, respectively (p = 0.048). During URS and RIRS, pulse shapes were significantly different, with Ho:YAG being used in long pulse and TFL in short pulse mode (all p < 0.05). We did not find further disparities.

CONCLUSION

Ho:YAG is used by most experts, while TFL is the most promising alternative. Laser settings largely do not vary significantly. However, further research with novel lasers is necessary to define the optimal approach. With the recent introduction of small caliber and more flexible scopes, minimal-invasive UTUC treatment is further undergoing an extension of applicability in appropriately selected patients.

The importance of second-look ureteroscopy implementation in the conservative management of upper tract urothelial carcinoma

PURPOSE

The purpose of the study was to evaluate the effect of second-look ureteroscopy (SU) in the endoscopic operative work-up of patients with upper tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

Patients with UTUC who underwent SU between 2016 and 2021 were included. Cancer detection rate (CDR) at SU was defined as endoscopic visualization of tumor. The effect of SU on recurrence-free survival (RFS), radical nephroureterectomy-free survival (RNU-FS), bladder cancer-free survival (BC-FS), and cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Multivariate logistic regression analysis (MLR) assessed predictors of negative SU. Finally, we evaluated the effect of SU timing on oncological outcomes, classifying SUs as "early" (≤ 8 weeks) and "late" (> 8 weeks).

RESULTS

Overall, 85 patients underwent SU. The CDR at SU was 44.7%. After a median follow-up was 35 (IQR: 15-56) months, patients with positive SU had a higher rate of UTUC recurrence (47.4% vs 19.1%, p = 0.01) and were more frequently radically treated (34.2% vs 8.5%, p = 0.007). Patients with high-grade disease (hazard ratio [HR]: 3.14, 95% CI 1.18-8.31; p = 0.02) had a higher risk of UTUC recurrence, while high-grade tumor (HR: 3.87, 95%CI 1.08-13.77; p = 0.04) and positive SU (HR: 4.56, 95%CI 1.05-22.81; p = 0.04) were both predictors of RNU. Low-grade tumors [odds ratio (OR): 5.26, 95%CI 1.81-17.07, p = 0.003] and tumor dimension < 20 mm (OR: 5.69, 95%CI 1.48-28.31, p = 0.01) were predictors of negative SU. Finally, no significant difference emerged regarding UTUC recurrence, RNU, BC-FS, and CSM between early vs. late SUs (all p > 0.05).

CONCLUSIONS

SU may help in identifying patients with UTUC experiencing an early recurrence after conservative treatment. Patients with low-grade and small tumors are those in which SU could be safely postponed after 8 weeks.

Long-Term Oncologic Outcomes of Endoscopic Management of High-Risk Upper Tract Urothelial Carcinoma: The Fundació Puigvert's Experience

Objectives: Many patients with upper tract urothelial carcinoma (UTUC) outside of the low-risk criteria may possess low absolute risks of distant progression. Herein, we hypothesized that careful selection of high-risk patients undergoing an endoscopic approach could result in acceptable oncologic outcomes. Materials and Methods: Patients with high-risk UTUC managed endoscopically between 2015 and 2021 were retrospectively identified from a prospectively maintained single academic institution database. Elective and imperative indications for endoscopic treatment were considered. Regarding elective indications, the decision to perform endoscopic treatment was systematically proposed to high-risk patients in whom macroscopically complete ablation was deemed feasible, excluding invasive appearance on CT scan, and without histologic variant. Results: A total of 60 patients with high-risk UTUC met our inclusion criteria (29 imperative and 31 elective indications). The median follow-up in patients without any event was 36 months. At 5 years, the estimated overall survival, cancer-specific survival, metastasis-free survival, UTUC recurrence-free survival, radical nephroureterectomy-free survival, and bladder recurrence-free survival were 57% (41-79), 75% (57-99), 86% (71-100), 56% (40-76), 81% (70-93), and 69% (54-88), respectively. All oncologic outcomes were similar between patients with elective and imperative indications (all log-rank p > 0.05). Conclusions: In conclusion, we report the first large series of endoscopic treatment in patients with high-risk UTUC, arguing that promising oncologic outcomes can be achieved in properly selected candidates. We encourage multi-institutional collaborative work as a large cohort of high-risk patients treated endoscopically may allow subgroup analyses to define the best candidates.

Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma

Current guidelines recommend endoscopic management (EM) for patients with low-risk upper urinary tract urothelial carcinoma, as well as those with an imperative indication. However, regardless of the tumor risk, radical nephroureterectomy is still mainly performed worldwide despite the benefits of EM, such as renal function maintenance, no hemodialysis requirement, and treatment cost reduction. This might be explained by the association of EM with a high risk of local recurrence and progression. Furthermore, the need for rigorous patient selection and close surveillance following EM may be relevant. Nevertheless, recent developments in diagnostic modalities, pathological evaluation, surgical devices and techniques, and intracavitary regimens have been reported, which may contribute to improved risk stratification and treatments with superior oncological outcomes. In this review, considering recent advances in endourology and oncology, we propose novel treatment strategies for optimal EM.

Salvage Percutaneous Cryoablation for Bleeding Upper Tract Urothelial Carcinoma

PURPOSE

Endoscopic access and treatment of bleeding upper urinary tract urothelial carcinomas (UTUCS) is sometimes difficult and inefficient as resection and/or laser coagulation are often incomplete. We report two cases of successful cryoablation of bleeding UTUCs.

MATERIALS AND METHODS

This study evaluated an adjunctive method in using cryoablation as a hemostatic technique. Cryoprobes were inserted inside the affected calices and a standard renal cryoablation protocol was used. Track ablation was performed during the pullback of the cryoprobes to prevent tumor seeding and bleeding.

RESULTS

Cryoablation of the bleeding upper urinary tract tumors allowed to efficiently resolve macrohematuria in both patients and to provide prolonged remission in one patient.

CONCLUSIONS

Taking advantage of the microcirculatory stasis and the hemostatic properties of cryoablation, we achieved palliative cessation of refractory macrohematuria while sparing nephrons, without the need for renal embolization in patients with bleeding UTUCs.

Effectiveness and Safety of Thulium Fiber Laser in the Conservative Management of Patients with Upper Tract Urothelial Carcinoma

Background

Few clinical data are available on thulium fiber laser (TFL) and conservative treatment of upper urinary tract urothelial carcinoma (UTUC).

Objective

To assess the effectiveness and safety of TFL in the conservative treatment of UTUC in terms of both tumor ablation and complication rates in a short-term follow-up.

Design setting and participants

Retrospective data were collected from all patients who underwent endoscopic management of UTUC between January 2021 and April 2022. All patients with nonmetastatic UTUC who were deemed suitable candidates (low- and high-grade disease) for conservative treatment were reviewed.

Intervention

All patients underwent ureteroscopy with biopsy and at 2, 6, and 12 mo after the first surgery. UTUC ablation was achieved using TFL.

Outcome measurements and statistical analysis

Clinical data were collected in a dedicated database. Intra- and postoperative outcomes were assessed. A descriptive statistical analysis was performed.

Results and limitations

In total, 28 patients were evaluated. Thirteen patients (46.4%) were included in the low-risk UTUC treatment group and 15 (53.6%) in the high-risk group. The mean tumor size was 15.3 ± 5.7 mm. Biopsy showed low- and high-grade UTUCs in 19 and eight patients, respectively. Only one biopsy was inconclusive for achieving a diagnosis. At the second procedure biopsy, no tumor was found in 19 cases (70.4%), whereas seven had tumors confirmed (25.9%). To date, 23 and 17 out of 26 patients completed the 6- and 12-mo follow-up, respectively. UTUC recurrence was detected in five of 23 patients (21.7%) and in three of 17 patients (17.7%) at 6 and 12 mo, respectively. A total of 95 procedures were performed. No intraoperative complications were observed. In ten of the 95 procedures (10.5%), Clavien-Dindo grade I-II postoperative complications were experienced. Only one grade IIIB postoperative complication was noted.

Conclusions

TFL is a safe and effective technique for conservative treatment of UTUC in a short-term follow-up. Optimal tumor ablation and fine hemostatic control were achieved without major complications.

Patient summary

In this study, we looked at the outcomes of upper urinary tract tumors conservatively treated with the new thulium fiber laser (TFL). We conclude that TFL represents a safe and effective technique for the treatment of this kind of tumors in a short-term follow-up.

Nephron-Sparing Approaches in Upper Tract Urothelial Carcinoma: Current and Future Strategies

Upper tract urothelial carcinoma (UTUC) is a relatively rare cancer, and much of the approach to treatment has been derived from strategies employed in treating bladder cancer. Radical nephroureterectomy (RNU) is regarded as the gold standard treatment for UTUC. However, due to potential complications, such as renal function impairment, that can affect oncologic outcomes, the demand for nephron-sparing treatment to effectively treat cancer while preserving renal function has increased. As a result, various treatment methods for low-grade, low-volume UTUC, such as segmental ureterectomy, endoscopic resection, and intraluminal therapy, have been attempted and reported. Although these treatment modalities have exhibited acceptable oncological results, further studies are required. In the future, the introduction of new technologies, such as improved diagnostic and surgical equipment, and new drug delivery systems, could enhance the effectiveness of nephron-sparing strategies in the treatment of UTUC. Additionally, understanding the biological and genetic characteristics of UTUC that distinguish it from those of bladder cancer will also aid in establishing strategies for nephron-sparing.

Laser technology in urologic oncology

Laser technology has been used in Urology since the 80s with a lot of different applications in endoscopic and open surgery. With the developments of the technology and the introduction of new active medium and source of laser energy, this technology have become the gold standard not only in stone surgery but even in benign prostate enlargement (BPE) surgical treatment. Regarding urologic oncology, laser energy has now reached an important role in focal therapy and in conservative treatment. The possibility of having better functional outcomes without any relevant impact on oncological results led to an increased use of laser in penile surgery, with a significant mention in urological guidelines for this option. In urothelial cancers as well, both in conservative management of upper tract tumors that in the treatment of non muscle invasive bladder cancer, a clear role of these relatively new source of energy have been demonstrated. Finally, both in prostate that in renal cancer the strategy of focal therapy may take advantage from this precise and fine technology. In this review we analyzed and described the applications of laser energy in urological cancers with a specific focus on penile, urothelial and prostate cancer.

Prognostic Value of Tumor Size in Patients with Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis

CONTEXT

The role of tumor size in predicting prognosis in upper tract urothelial carcinoma (UTUC) patients remains poorly defined.

OBJECTIVE

To assess the prognostic value of tumor size in patients with UTUC through a systematic review and meta-analysis.

EVIDENCE ACQUISITION

A comprehensive literature search of the PubMed and Embase databases were performed to identify all relevant articles published up to December 2021 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Available hazard ratios (HRs) and corresponding 95% confidence intervals (95% CIs) were analyzed to evaluate the association between tumor size and survival outcomes.

EVIDENCE SYNTHESIS

A total of 35 articles representing 32 292 patients met the eligibility criteria and were finally included for the meta-analysis. Tumor size was significantly associated with poor outcomes in terms of overall survival (HR = 1.42, 95% CI = 1.28-1.58), cancer-specific survival (HR = 1.66, 95% CI = 1.47-1.88), recurrence-free survival (HR = 1.25, 95% CI = 1.13-1.38), and intravesical recurrence (HR = 1.12, 95% CI = 1.04-1.20). There was between-study heterogeneity in the effect of tumor size on all these meta-analyses, with p < 0.10 and I2 generally >50%. Subgroup analyses illustrated that the association of tumor size with adverse prognosis in UTUC patients is not affected by treatment modalities. Segmental resection of ureter, whether receiving lymph node dissection, cutoff of tumor size, and region of population were potential sources of heterogeneity. The funnel plot test indicated no significant publication bias in the meta-analysis of survival outcomes.

CONCLUSIONS

This study shows that larger tumor size is associated with an increased risk of overall and cancer-specific mortality, and disease recurrence in UTUC. Integration of tumor size with other prognostic indicators may help in risk stratification and individualized treatment of UTUC.

PATIENT SUMMARY

Through a systematic review and meta-analysis, this study found that larger tumor size is associated with an increased risk of overall and cancer-specific mortality, and disease recurrence in patients with upper tract urothelial carcinoma.