The Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) are delighted to lend our enthusiastic support to the sixth World Patient Safety Day (WPSD). This event, established by the World Health Organisation (WHO) in 2019, takes place on 17 September every year. It helps to raise global awareness amongst all stakeholders about key Patient Safety issues and foster collaboration between patients, health care workers, health care leaders and policy makers to improve patient safety. Each year a new theme is selected to highlight a priority patient safety area for action.
The theme set by the WHO for this year’s WPSD is “Improving diagnosis for patient safety”, recognising the vital importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.
Upper tract urothelial cancer (UTUC) is a cancer originating from the lining of the drainage system of the kidneys including the renal pelvis and ureters. This is a relatively rare urological cancer which affects 2/100000 people in the UK. It is the same type of cancer which commonly affects the bladder. However, UTUC is typically regarded as more aggressive than bladder cancer owing to its later presentation with higher grade and stage of disease and confers a poorer five-year overall survival.
Diagnosis of UTUC is often made initially on CT of the urinary tract. Surgery to remove the kidney and ureter (nephro-ureterectomy) is the standard of care for most patients with UTUC. Prior to definitive surgery, confirmation of the diagnosis of UTUC is facilitated by cytological assessment of the urine and/or diagnostic ureteroscopy, with or without biopsy. Unfortunately, diagnostic ureteroscopy in particularly can delay the time to definitive surgery and there is increasing concern that this diagnostic procedure could increase the risk of the tumour spreading from the ureter into the bladder. There is therefore a balance to be had between having confidence in the diagnosis of UTUC before embarking on major surgery for disease cure, reducing the time to definitive surgery by omitting unnecessary investigations and avoiding investigations which could cause harm without benefit.
To address these issues, the team in NHS Lothian’s Department of Urology audited all patients who had investigation for suspected UTUC between 2011 and 2017 to determine the utility of diagnostic ureteroscopy. They then assessed baseline characteristics to determine if there was a group of patients who could safely omit diagnostic ureteroscopy prior to definitive surgery.
During the study period 260 patients were investigated for suspect UTUC with 230 of them undergoing diagnostic ureteroscopy during their diagnostic pathway. Importantly diagnostic ureteroscopy prevented unnecessary nephro-ureterectomy in one third of patients who did not have a diagnosis of UTUC, highlighting it’s continued importance in the diagnostic process. However, on analysis of all patients baseline characteristics, presentation with blood in the urine, a history of smoking and a solid appearing tumour on the initial CT scan were all predictive of a diagnosis of UTUC. Patients with all 3 characteristics had a 96.2% risk of UTUC. This data suggested with appropriate counselling, patients with these characteristics could safely avoid diagnostic ureteroscopy and reduce the time from referral to treatment by an average of 45 days.
As a result of this work, the Department of Urology in NHS Lothian now determine patients’ individual risk of UTUC when the patient’s case is discussed at the multi-disciplinary team meeting and the use of diagnostic ureteroscopy is recommended on a case-by case basis. The rationale for and against diagnostic ureteroscopy is always discussed with patients before making a final decision. As a result of these changes, between 2022 and 2023, 45% of patients now proceed directly to nephro-ureterectomy without diagnostic ureteroscopy compared with 16% previously. This has resulted in a reduction in time from referral to treatment by an average of 70 days without any nephro-ureterctomies being performed unnecessarily for benign disease.
Written by Mr Alexander Laird PhD FRCSEd(Urol), Consultant Urological Surgeon and Honorary Clinical Senior Lecturer, Department of Urology, The University of Edinburgh
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