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Endoscopic diagnosis of Upper tract Transitional Cell carcinoma: Correlating indications with investigations and Histology Finch W, Shah N, Wiseman O Department of Urology, Addenbrookes Hospital, Cambridge Purpose: To determine the referral pattern and accuracy of ureteroscopy, biopsy and cytology in predicting upper-tract transitional cell carcinoma (TCC) Materials and methods: From November 2004 to date, 85 diagnostic ureteroscopies were performed with 40 resulting in a diagnosis of TCC . Indications for referral, radiological, ureteroscopic and cytology results were correlated with diagnosis. Ureteroscopic biopsy data was compared with final histology of 12 nephroureterectomy specimens. Results: 85 diagnostic ureteroscopies were performed of which 10 were deemed complex (ileal conduit, prior distal ureterectomy, horseshoe kidney). Indications for referral resulting in a positive diagnosis of TCC were: filling defect on imaging – 34%, positive voided urine cytology – 67% , atypical voided urine cytology – 14%, haematuria ?cause – 0%. When a filling defect was seen in combination with positive or atypical cytology, the chance of TCC diagnosis was 89% and 83% respectively. Operative retrograde was predictive of TCC in 78% of cases. Ureteroscopy demonstrated TCC in 90% of cases, with distal ureteric and renal pelvis TCC seen most commonly. Ureteric and renal pelvis washings for cytology were postive for TCC in 52% and 65% of cases respectively. 26 ureteroscopic biopsies were performed; 77% TCC, 8% benign and 15% uninterpretable. 12 ureteroscopic biopsies were correlated with final histology. Of these; 2 (17%) were uninterpretable, 1 (8%) was reported as benign, 1 (8%) correctly identified the final histology and 8 (67%) were upstaged, upgraded or both on final histology. Conclusions: This study highlights the fact that endoscopic investigation for upper tract TCC is not straightforward. Failure to investigate thoroughly may result in unnecessary major surgery for benign disease. Endoscopic investigation is crucial to identify those patients with upper tract TCC, including those not amenable to conservative therapy. Positive ureteric and renal pelvic cytology is helpful in identifying those patients with higher grade disease. Ureteroscopic biopsies are not accurate in determining grade or stage of the disease, but do help identify patients with higher grade disease not amenable to conservative therapy.
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