What is included in the long-term monitoring of urothelial tumors of the renal pelvis and ureters?

Updated: Aug 07, 2020
  • Author: Kyle A Richards, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Follow-up is largely determined by tumor grade and stage and the procedure performed. In cases in which a radical nephroureterectomy is performed, local recurrence is uncommon. Bladder recurrence rates vary per report, from 15-50%. The bladder should be surveyed routinely.

In patients managed conservatively or with endoscopic techniques, closer follow-up intervals are warranted. Surveillance ureteroscopy under local anesthesia in the clinic is feasible and well tolerated in selected patients. The high rate of recurrence mandates strict postoperative surveillance for any renal-sparing treatment strategy used for upper-tract urothelial tumors.

The American Urological Association has no guideline on follow-up and surveillance. A generally accepted surveillance protocol consists of cystoscopy and selective urine cytology at 3-month intervals postoperatively for the first year and every 6 months during the second year. CT urography, excretory urography, or retrograde ureteropyelography can be performed at 3- to 6-month intervals to evaluate the upper tract. Ureteroscopy is the most sensitive tool for detecting recurrence and is performed routinely at 3-month intervals initially, with the frequency increasing to 6 months after the first year. At 2-5 years, cystoscopy and ureteroscopy are continued at 6-month intervals.

As mentioned above, ureteroscopy is the preferred surveillance tool for detecting recurrences after endoscopic ablation of upper tract transitional cell carcinoma (TCC).

Ureteroscopy with biopsy and cytology yields a sensitivity of 93.4% and specificity of 65.2%. In the same series, surveillance with retrograde pyelography had a sensitivity and specificity of 71.7% and 84.7%, respectively. [62]

Voided urine cytology and microscopic hematuria yield a low sensitivity but reasonable specificity in detecting upper tract recurrences.

Upon any recurrence, the endoscopic cycle is restarted.

The contralateral collecting system is studied radiographically once yearly with CT urography, retrograde pyelography, or intravenous pyelography and cytology. Surveillance cystoscopy and imaging of the contralateral upper tract is also required to detect recurrences in patients treated with nephroureterectomy.

Several novel markers in addition to urine cytology and fluorescence in situ hybridization (FISH) may be helpful in detecting recurrent urothelial carcinoma. A prospective study by Siemens et al determined that the accuracy of diagnostic markers was as follows [63] :

  • Urinary fibrinogen/fibrin degradation products (FDPs) – Sensitivity 100%, specificity 83%
  • Bladder tumor antigen (BTA) – Sensitivity 50%, specificity 62%
  • Urine cytology – Sensitivity 29%, specificity 59%

For patient education resources, see the Cancer and Tumors Center and Kidneys and Urinary System Center, as well as Bladder Cancer, Blood in the Urine, Intravenous Pyelogram, and Cystoscopy.


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