TOPLINE

A combined CT urography and urinary cytology surveillance strategy in patients managed with endoscopic kidney-sparing surgery for upper tract urothelial carcinoma would have avoided more than two thirds of ureteroscopies but missed nearly two thirds of recurrences.

METHODOLOGY

• Researchers conducted a retrospective cohort study including patients with upper tract urothelial carcinoma managed with primary endoscopic kidney-sparing surgery at two tertiary referral centers, in Paris and Milan, from 2006 to 2025.
• They compared the performance of CT urography and urinary cytology with ureteroscopy findings among 133 patients (median age, 70 years) who underwent 256 ureteroscopic procedures.
• Patients underwent an intensified surveillance protocol that included obligatory second-look ureteroscopy at 4-6 weeks, followed by ureteroscopy exams along with cystoscopy, imaging, and urinary cytology every 4-6 months during the initial 2 years, then transitioning to 9-12-month intervals. CT and/or urinary cytology was performed before each ureteroscopy.
• The concordance of preoperative assessment with ureteroscopy findings was assessed, with four preoperative trigger strategies tested: CT or cytology positive, cytology positive alone, CT positive alone, and both CT and cytology positive.
• Diagnostic performance was assessed; measures included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and miss rate. Recurrence rates were analyzed, and radical nephroureterectomy was indicated for upstaging, upgrading, radiologic progression, or disease incapable of being managed endoscopically during follow-up.

TAKEAWAY

• Of all procedures, nearly half (49%) yielded negative results. Preoperative cytology was positive in 11% of procedures, and CT scans showed positive findings in 29%.
• Urinary cytology alone showed a high specificity (97%) for detecting recurrence, but its sensitivity was only 11%; CT urography alone showed 27% sensitivity and 78% specificity; requiring both tests to be positive achieved 100% specificity but only 2.8% sensitivity.
• The sensitivity and specificity for detecting recurrence using the combined definition of preoperative positivity (CT and/or cytology) was 36% and 75%, respectively, with a PPV of 64% and an NPV of 48%. Employing a combined trigger strategy would have prevented 69.2% of ureteroscopy procedures; however, this approach would have led to 64.5% of the recurrences being missed.
• Among procedures classified as false negative by the combined CT and/or cytology trigger, 81.3% were low-grade recurrences and 6.6% were high-grade recurrences, though 20.9% of these false-negative cases were later followed by radical nephroureterectomy. Annual recurrence rates stayed stable across 4 years of follow-up in the low-risk and high-risk groups.

IN PRACTICE

"[The study] findings indicate that non-invasive tests alone are not sufficiently sensitive to safely replace URS [ureteroscopy] surveillance," the authors wrote.

"URS therefore remains a key component of follow-up, whereas non-invasive tests should be considered complementary tools for risk stratification rather than substitutes for endoscopic surveillance," they added.

SOURCE

The study was led by Pietro Scilipoti, Service d’urologie, Tenon Hôpital in Paris, France. It was published online on September 28, 2026, in BJU International.

LIMITATIONS

The retrospective study design and patient inclusion from only two centers may limit generalizability and introduce selection bias. The unit of analysis was the ureteroscopy procedure rather than the patient, which meant that repeated observations from the same individual were not strictly independent. Imaging or cytology methods were not standardized over the study period and are subject to interobserver variability.

DISCLOSURES

The study did not receive any specific funding. Two authors disclosed having consulting ties with device companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.