Diagnosis and evaluation of upper tract urothelial carcinoma (utuc)

Upper tract urothelial carcinomas (UTUC) are scarce and account for only 5–10 % of urothelial carcinomas. The estimated annual incidence of UTUC in Western countries is about 1–2 new cases per 100,000 inhabitants. Pyelocaliceal tumors are about twice as common as ureteral tumors. The diagnosis of a UTUC may be fortuitous or related to the exploration of symptoms. The symptoms are generally restricted. The most common symptom of UTUC is gross or microscopic haematuria (70–80 %). Flank pain occurs in 20–40 % of cases, and a lumbar mass is present in 10–20 %. In case of UTUC, a cystoscopy is mandatory to rule out a concomitant bladder tumor. Positive urine cytology is highly suggestive of UTUC when bladder cystoscopy is normal and if CIS of the bladder or prostatic urethra has been largely excluded (e.g., by biopsies of any suspicious lesion, possibly guided by photodynamic diagnosis). Cytology is less sensitive for UTUC than for bladder tumors, even for high-grade lesions, and it should ideally be performed in situ (i.e., in the renal cavities). Retrograde ureteropyelography (through a ureteral catheter or during ureteroscopy) remains an option for the exclusion of a tumor in the upper urinary tract. Computed tomography (CT) urography is the imaging technique with the highest diagnostic accuracy for UTUC and has replaced intravenous excretory urography and ultrasonography as the fi rst-line imaging test for investigating high- risk patients. In addition, the possible advantages of ureteroscopy should be discussed in the preoperative assessment of any UTUC patient. Flexible ureteroscopy is used to visualize and biopsy the ureter, renal pelvis, and collecting system with a technical success approaching 95 %. Such ureteroscopic biopsies can determine tumor grade in 90 % of cases with a low false-negative rate regardless of the size of the sample. Ureteroscopy also facilitates selective ureteral sampling for cytology in situ. Flexible ureteroscopy is especially useful when there is diagnostic uncertainty, in patients with a solitary kidney, or when conservative treatment is being considered.