输尿管镜活检可协助上尿路尿路上皮癌危险分层

目的：分析输尿管镜活检对上尿路尿路上皮癌（upper tract urothelial carcinoma,UTUC）患者肿瘤级别、肌层浸润以及多灶性诊断的准确性，分析术后肿瘤级别及肌层浸润的相关因素，探讨输尿管镜活检对UTUC患者术前危险分层的可行性与必要性。方法：回顾性分析北京大学第三医院泌尿外科2014年1月至2016年12月间输尿管镜活检后行肾、输尿管全长及膀胱输尿管口袖状切除术患者的临床资料。结果：患者76例，男性31例（40.8%）、女性45例（59.2%），平均年龄64.5岁（31~88岁）。肿瘤位于左侧35例、右侧41例，肾盂39例、输尿管37例，症状为肉眼血尿者51例。术后病理提示低级别21例（27.6%）、高级别51例（67.1%），未确定级别4例（5.3%）；非肌层浸润27例（35.5%）、肌层浸润47例（61.9%），无法确认是否浸润2例（2.6%）；术后病理均为UTUC。在50名输尿管镜活检可判断肿瘤级别的患者中，活检病理对低级别尿路上皮癌诊断的敏感性、特异性和准确性分别为88.2%、69.7%和76.0%，阳性和阴性预测值分别为60.0%和92.0%。在27例活检病理可以判断是否有肌层浸润的患者中，5例活检报告为肌层浸润的UTUC患者术后病理结果均有肌层浸润，22例报告为非肌层浸润的患者术后肌层浸润和非肌层浸润各占50%，总准确性为59.3%。输尿管镜活检对于肿物多灶性诊断的准确性为61.0%。单因素分析显示，输尿管镜活检级别与术后UTUC级别相关（P=0.001），而性别、年龄、边侧、体重指数（body mass index，BMI）、血尿、术前肾小球滤过率估计值（estimated glomerular filtration rate，eGFR）、泌尿系积水、肿瘤大小、位置、多灶性及是否有蒂均与术后UTUC级别无显著相关性。输尿管镜活检病理高级别（P=0.02）、术前eGFR＜90 mL/(min·1.73 m2)（P=0.025）以及病变位于肾盂（P=0.049）与肌层浸润显著相关，性别、年龄、边侧、BMI、血尿、泌尿系积水、肿瘤大小、多灶性及是否有蒂与其无显著相关性。结论：输尿管镜活检可协助对UTUC患者进行危险分层。

Ureteroscope can assist risk stratification in upper tract urothelial carcinoma

Objective: To analyze the efficiency of ureteroscope and biopsy in the diagnosis of tumor grade, muscle-invasiveness and multifocality in suspected upper tract urinary carcinoma (UTUC) patients in order to find out whether it can be used in the risk stratification of UTUC patients.Methods: A retrospective study of 76 UTUC patients who underwent preoperative ureteroscope and/or biopsy and received radical nephroureterectomy in Peking University Third Hospital during January 2014 to December 2016 was undertaken.Results: In this study, 76 patients were included.There were 31 males (40.8%), and 45 females (59.2%).The median age was 64.5 years (31-88), and 51 patients had the symptom of hematuresis.The tumor was located in renal pelvis in 39 patients, and in ureter in 37 patients.Post-operative pathology confirmed that all the 76 patients included in this study suffered from UTUC, of whom 21 (21.6%) were of low-grade, 51 (67.1%) were of high-grade, 4 (5.3%) were undetermined, and 47 (61.9%) patients were muscle-invasive, and 27 (35.5%) were not, and 2 (2.6%) were undetermined.Among the 50 patients, in whom the grade of the tumor could be diagnosed by biopsy, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value for low-grade tumor was 88.2%, 69.7%, 76.0%, 60.0% and 92.0%, respectively.Among the 27 patients, in whom the muscle-invasiveness could be diagnosed by biopsy, 5 patients were diagnosed with muscle-invasiveness, all confirmed by pathology after surgery and 22 patients were diagnosed with none muscle-invasiveness, turned out to be 50% muscle-invasive and 50% none-muscle invasive after surgery.The accuracy was 59.3%.The accuracy of ureteroscopic biopsy to diagnosis multifocality was 61.0%.On univariate ana-lysis, biopsy grade was associated with postoperative pathology (P=0.001), while gender, age, side, body mass index (BMI), hematuresis, preoperative estimated glomerular filtration rate (eGFR), hydronephrosis, tumor size, location, multifocality and sessile were not associated with postoperative pathology grade.Biopsy grade (P=0.02), preoperative eGFR<90 mL/(min·1.73 m2)(P=0.025) and tumor located in pelvis (P=0.049) were associated with muscle invasiveness.Gender, age, side, BMI, hematuresis, hydronephrosis, tumor size, multifocality and sessile were not significantly associated with muscle invasiveness.Conclusion: Ureteroscope and biopsy can assist risk stratification in upper tract urothelial carcinoma patients.