The application of diagnostic digital flexible ureteroscopy in patient with hematuria from unilateral upper urinary tract

Objective To investigate the value of diagnostic digital flexible ureteroscopy in patient with hematuria from unilateral upper urinary tract. Methods A retrospective analysis was made in consecutive 140 cases, including 94 males and 46 females, who are considered for hematuria from unilateral upper urinary tract in Renmin hospital of Wuhan University from January 2014 to February 2019.Their age ranged from 22 to 89 years, with mean of 62.3 years. The mean BMI was 24.6 kg/m2(ranging 22.1-28.2 kg/m2). All patients complained about the continuously or intermittently gross hematuria. 29 cases (20.7%) complained about the flank pain, as well. All cases were examined by urinary sonography, CTU and voided urine cytology preoperatively. Occupying lesion was found in 47 case by sonography including suspected diagnosis. Upper tract urothelial carcinoma(UTUC) was diagnosed in 63 cases by CTU including suspected diagnosis.Voided cytology was positive in 17 cases. Concomitant bladder or urethral lesions were excluded by cystoscopy. Hematuria was confirmed from left side in 82 cases(58.6%) and from right side in 58 cases(41.4%). Diagnostic digital flexible ureteroscopy were performed under general anethesia strictly according to 'No touch technique’. Biopsy for suspicious lesions as well as selective in situ cytology were acquired during ureteroscopy. Results All patients accepted the examination successfully. The duration of follow-up ranged from 3 to 37 months, with mean of 13 month. Benign lesions were found in 71 cases(50.7%) while malignant lesions were identified in 69 cases(49.3%). Benign lesions included 39(54.9%)minute venous rupture, 12 (16.9%)hemangioma, 3 (4.2%)varix and 11 (15.5%)no obvious lesion. The overall success rate of ureteroscopic treatment was 66(93.0%) whereas recurrence rate after treatment was 8(11.3%). Malignant lesions including 67(97.1%) cases with UTUC and 2 cases with squamous carcinoma. The radical nephroureterectomy(RNU)and bladder sleeve resection was performed in all cases. To 67 cases with UTUC, the overall identification rate of urinary sonography, CTU, voided urine cytology, selective in situ cytology and diagnostic digital flexible ureteroscopy was 41(61.2%), 61(91.0%), 13(19.4%), 38(56.7%) and 63(94.0%) respectively. Identification rate of selective in situ cytology was superior to voided cytology(P<0.01) while diagnostic digital flexible ureteroscopy was no significant difference compared with CTU. The concordance of pathological grade between biopsy and final resection specimen was 73.1%.The concordance of low grade was 93.3% whereas high grade was 56.8%. Up-grading was found in 16(23.9%) cases while down-grading was found in 2(3.0%) cases. Intravesical recurrence was affirmed in 11(16.4%) cases during follow-up. Conclusions Diagnostic digital flexible ureteroscopy may not only present qualitative as well as localized evidence for etiological diagnosis of hematuria from unilateral upper urinary tract, but also provides strategy choice for treatment. Key words: Ureteroscopy; Flexible ureteroscope; Hematuria; Upper urinary tract; Upper tract urothelial carcinoma; Laser ablation