Upper urinary tract: challenges and prospects

Cancer experts discussed the challenges in the diagnostics and optimal treatment for upper urinary tract cancers and said that despite advances in imaging technology the question when to use radical or conservative treatment remains a tricky issue for many doctors.

“Diagnosing and treating upper urinary tract cancers remains a challenge. Opportunities for diagnostic methods and the use of imaging techniques increasingly play a role in our diagnosis and treatment strategies, but dilemmas on optimal treatment remain,” said Prof. Francesco Montorsi (IT) who co-chaired the plenary session with Prof. Freddie Hamdy (GB).

Issues in diagnosing upper tract urothelial cancer were examined by Prof. Maria Pilar Laguna (NL) in her update lecture. She said that although the disease is rare and accounts for a small segment of urological cancers, its aggressiveness poses a challenge. Providing a comprehensive view on diagnostics such as imaging and role of cytology, Laguna noted that technology alone is not sufficient to resolve pertinent questions.

"A major dilemma remains which is to assign adequate grade and stage by means of the diagnostic tests at hand,” she said and added that there is a lack of “…robust histological information on endoscopic biopsy, with around 40% of upgrading and upstaging at NU (nephroureterectomy).” Laguna: “Visual enhancement of the tumours increases diagnostic yield but benefit in accuracy on grade and stage determination remains to be proven.”

Promising and emerging tools include Optical Coherence Tomography (OCT) and gene typing in urine, which may increase diagnostic yield and grade-stage accuracy, she said.

A discussion on how much surgery for upper urinary tract urothelial carcinoma (UUTUC) presented the views of Professors Shahrokh Shariat (USA), Olivier Traxer (FR) and Maurizio Brausi (IT). They looked into the pros and cons of organ-sparing approaches, the benefits of modern imaging, and the roles of radical surgery and lymphadenectomy. A selection of their key messages are:

• Shariat: “Treatment is more and more based primarily on the risk of the tumour and efficacy of therapy rather than practical limitations; role of LND during segmental ureterectomy remains to be evaluated."
• Brausi: “Lymphadenectomy (LND) improves disease staging and helps in selecting patients who can benefit from chemotherapy; Several retrospective studies suggest the potential therapeutic role of LND during nephron-ureterectomy for transitional cell carcinoma of the upper urinary tract.
• Traxer: “Regarding endoscopic treatment, flexible URS (ureterorenoscopy)for diagnostic is recommended, and new tools for better detection are needed such as narrow band imaging (NBI).”