Table 1.
Recommendations for diagnosis and management of low risk tumors.
| Recommendations for endoscopic management | LEV | GOR |
|---|---|---|
| Unifocal | 3 | B |
| Small lesions (<2cm) | 3 | C |
| Low-grade tumor on biopsy | 3 | B |
| Negative cytology | 3 | C |
| Complete visualization | 3 | B |
| Papillary tumor | 3 | B |
| Good compliance | 3 | B |
| Understanding of invasive and close follow-up | 3 | B |
| All other tumor or patients features should be treated only in very selected patients with endoscopic treatment Recommendations for imaging | 3 | B |
| Imaging should be performed for exclusion of endoscopic treatment | 3 | B |
| CT-Urography should be performed for staging | 3 | B |
| Retrograde urography should be performed during endoscopic evaluation | 3 | C |
| Recommendations for diagnostic ureteroscopy | ||
| Ureteroscopic inspection of UTUC alone, without biopsy, has a very limited role, thus, biopsies are recommended | 3 | B |
| Tumor architecture, multifocality, number of lesions, size of lesions and their localizations should be documented | 3 | C |
| Localizations should also be evaluated for accessibility (need for flexible ureteroscopy, percutaneous approach) | 3 | C |
| Cystoscopy should be performed to exclude bladder cancer (up to 15%) | 3 | B |
| Recommendations for biopsy | ||
| Retrograde pyelography should be performed | 3 | C |
| Ureteroscopy should be performed | 3 | B |
| Flexible Ureteroscopy has technical advantages, especially for performing biopsies | 3 | C |
| The percutaneous approach is reserved for special indications | 3 | B |
| The biopsy can be performed using cup biopsies or using the basket | 3 | C |
| Ureteroscopic biopsy should be performed before endoscopic treatment | 3 | C |
| Number of biopsies should be more than 1 | 3 | C |
| Biopsy should distinguish between low and high-grade tumors | 3 | B |
| Grade is a surrogate marker. G1 correlates with low grade and low stage disease, whereas high grade correlates with high grade and high stage disease. | 3 | B |
| G2 alone is insufficient for the decision of endoscopic treatment, especially in elective cases. | 3 | B |
| The use of access sheets should be avoided during diagnostic approach | 4 | C |
| Recommendations for cytology and markers | ||
| Malignant tumor cells on urinary cytology suggest high grade / CIS disease | 3 | B |
| Cytology should be performed, because it can add information for decision making, however, voiding voided cytology is of little value. | 3 | C |
| Selective cytology from the upper tract should be considered to detect high grade and CIS | 3 | B |
| Urine markers like fluorescence in situ hybridization can increase sensitivity in experienced hands | 3 | C |
| Cytology should be done before using contrast agents and instrumentation because manipulation can lead to erroneous results | 3 | B |
LEV = Level of evidence; GOR = Grade of recommendation