The objective of this study was to assess the necessity of performing ureteroscopic biopsy prior to nephroureterectomy (NU) in patients with suspected upper urothelial tract cancer (UTUC).

This retrospective study included patients referred between 2015 and 2022 with suspected UTUC. Clinicopathological data such as mode of presentation, CT imaging findings, urine cytology results, ureteric biopsy outcomes, and final histopathological diagnoses were collected. Data were analyzed using SPSS.

A total of 161 patients were included in the study. The primary modes of presentation were hematuria (48%), CT-detected filling defects (54%), ureteric thickening (8%), locally advanced disease (11%), and inconclusive findings (17%). Urine cytology was positive for malignancy in 13% (n=21) of cases.

Of the 161 patients, 89 underwent nephroureterectomy, which were divided into two cohorts: Group 1, who underwent prior ureteric biopsy (n=39), and Group 2, who did not undergo biopsy prior to surgery (n=50). Histopathological analysis of the nephroureterectomy specimens revealed that 4 patients in Group 1 and 10 patients in Group 2 had a histological diagnosis different from UTUC. This suggests that 10% of patients in Group 1 avoided unnecessary NU, while 20% of patients in Group 2 could have potentially undergone alternative treatment options instead of NU if a prior biopsy had been performed.

Among the patients who had a prior ureteric biopsy, 5 experienced upstaging of histological grade on the final nephroureterectomy specimen. A significant association was found between histological grade on biopsy and histological grade on the NU specimen (p=0.04), particularly in high-grade disease.

The findings of this study highlight the clinical utility of ureteroscopic biopsy in accurately diagnosing UTUC and determining the need for nephroureterectomy. In Group 1, the 10% of patients who avoided unnecessary NU demonstrates the potential benefit of biopsy in identifying patients who might otherwise be treated with radical surgery unnecessarily. In contrast, the 20% of patients in Group 2 who could have benefited from a prior biopsy indicates that lack of biopsy in this group could lead to unnecessary radical surgeries or missed alternative treatment options.

Furthermore, the upstaging of histological grade in 5 patients with prior biopsy underscores the importance of biopsy in detecting higher-grade disease, which might alter the management strategy. The statistically significant association (p=0.04) between histological grade on biopsy and histological grade on nephroureterectomy specimen, particularly in high-grade disease, supports the concept that prior biopsy can provide critical insights into the tumor's aggressiveness, potentially influencing surgical decision-making.

Initial diagnostic ureteroscopy plays a critical role in accurately identifying UTUC patients who require radical surgery, as well as ruling out conditions that might be managed with alternative, less invasive treatments. In patients with clear CT imaging indicative of UTUC, and a history of bladder cancer or abnormal urine cytology, ureteroscopic biopsy may be safely omitted. This study suggests that while ureteric biopsy can influence treatment decisions, its necessity should be carefully considered in specific patient populations, especially when imaging and clinical history strongly suggest UTUC.