Can excretory urography detect upper urinary tract tumors after radical cystectomy for urothelial cancer?

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Abstract

BACKGROUND

The use of excretory urography for the detection of upper urinary tract tumors (UUTTs) in patients with urothelial cancer who have undergone radical cystectomy is controversial.

OBJECTIVE

To assess the efficacy of excretory urography for detecting UUTTs in these patients.

DESIGN AND INTERVENTION

This retrospective study included data from a single-institution, prospective database of patients with transitional cell carcinoma (TCC) of the bladder who had undergone radical cystectomy and ileal orthotopic bladder substitution between April 1985 and July 2006. Patients were excluded if they had <12 months follow-up. All patients' ureteral margins were sent for frozen section analysis. Follow-up investigations were performed at 3 and 6 months postsurgery, biannually until year 5, and annually thereafter; investigations included physical examination, body weight measurement, chest X-ray, ultrasonography of the kidney, postvoid residual urine volume measurement, urethral cytology and blood chemistry. Excretory urography was also performed at year 1, 2, 3, 5, 7 and 10. If UUTTs were detected, patients underwent treatment that included nephroureterectomy or Bacillus Calmette-Guérin.

OUTCOME MEASURES

The primary outcome measure was the percentage of patients with UUTTs that were detected by excretory urography.

RESULTS

The study included 322 patients, of whom 83 had multifocal pTa or recurrent pT1 tumors, 232 had pT2-4 tumors, and 7 had no histological findings available. Concomitant carcinoma in situ was present in 37 (44.6%) patients with multifocal pTa or recurrent pT1 tumors and 73 (31.5%) patients with pT2-4 tumors. The median patient age was 65 years, 93% of patients were male, and the median follow-up period was 49 months. UUTTs developed in 15 (4.7%) patients: 7 (8.4%) patients with multifocal pTa or recurrent pT1 tumors, of whom 1 (2.7%) had concomitant carcinoma in situ; and 8 (3.4%) patients with pT2-4 tumors, of whom 7 (9.6%) had concomitant carcinoma in situ. Of the 15 patients who developed UUTT, 4 (27%) had a history of upper tract TCC, and 6 (40%) patients had a positive margin. Excretory urography was performed 1,064 times, and detected UUTTs in 8 (53%) of the patients at a median of 26 months; the other 7 (47%) patients' UUTTs were detected by further examinations at a median of 47 months. Of the 8 patients whose UUTTs were detected by excretory urography, 5 patients died of TCC, 1 patient died of another cause, and 2 patients had no evidence of disease at 19 and 24 months after nephroureterectomy for UUTT. Of the 7 patients whose UUTTs were detected by other examinations, 3 patients died of TCC, 1 patient died of another cause, 2 patients had progressive disease, and 1 patient had no evidence of disease 35 months after surgery.

CONCLUSIONS

Excretory urography was not efficient at detecting UUTT. Patient outcomes after UUTT diagnosis were poor; therefore, excretory urography should not be recommended. Other diagnostic techniques should be used in patients at high risk of UUTT.

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