Deciphering and Determining Low-Grade UTUC: Diagnosis, Staging, and Grading

A roundtable discussion, moderated by Katie S. Murray, DO, MS, discussed the risk stratification and treatment options for low-grade upper tract urothelial carcinoma (UTUC), as well as recent trial data from the 2024 American Urological Association (AUA) Annual Meeting. Dr. Murray was joined by Scot Niglio, MD; Alice Yu, MD; Hong Truong, MD, MS; and Adam Feldman, MD, MPH.

In the second segment of the roundtable series, the panel provides a disease state overview of low-grade UTUC, including considerations for diagnosis, staging, and grading.

Watch the next segment in this series.

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Dr. Murray: Let us dive into low-grade UTUC. It is already a small subset of patients dealing with upper tract disease, and within that, low-grade cases are even rarer. Urologists know that diagnosis, staging, and grading can be quite complex. Does anyone have any tricks they use to ensure a confident diagnosis of low-grade versus high-grade disease when performing ureteroscopy?

Dr. Feldman: Tissue is key. Take plenty of biopsies. Personally, I use piranha biopsy forceps instead of BIGopsy, along with a basket if needed. Getting as much tissue as possible and handling it properly is crucial.

Dr. Yu: I have tried smaller graspers before but found they did not yield enough tissue for diagnosis, which was frustrating. I often send cytology samples as well. Recently, I have been using larger graspers despite the added challenge. Getting the right diagnosis is crucial for managing the disease effectively.

Dr. Murray: When you suspect disease and plan a ureteroscopy and biopsy, do you attempt endoscopic ablation during the procedure? How do you discuss this with the patient beforehand?

Dr. Truong: I explain to the patient that any upper tract tumor seen on a CT urogram requires evaluation. First, we do cystoscopy to rule out bladder tumors, which we can address during the ureteroscopy. We also collect urine for cytology. Risk stratification relies on both cytology and pathology. Sometimes there is a discrepancy, indicating tumor heterogeneity. If cytology suggests high-grade and pathology shows low-grade, there may be high-grade tumors elsewhere.

Regarding ureteroscopic ablation, I aim to obtain good tissue specimens for pathology before the procedure becomes too bloody or difficult to see. If the tumor looks suitable for complete endoscopic ablation without risking ureter perforation, I proceed.

Dr. Feldman: The operative plan starts in the office. Assess the patient’s imaging carefully. I have had cases where a low-grade diagnosis did not match the imaging findings. We look at the size of the mass, its visibility on imaging, any surrounding fat stranding, and potential adenopathy. Renal function is also crucial; will nephroureterectomy risk dialysis? We discuss whether to manage the patient endoscopically to preserve renal function. These nuances are essential in planning treatment.

Dr. Yu: Planning for upper tract endoscopy is challenging. Counseling in the office is extensive, and the consent form lists various possibilities, including ablation and stent placement. Imaging is critical, but sometimes surprises happen once you are in there. For me, it boils down to tumor size and safety for ablation. Small tumors under one centimeter are manageable, but anything over 2 centimeters is a no-go.

Dr. Feldman: My favorite question in the OR is which cases will win the laser treatment. We will see!

Dr. Murray: All of the above.