Teaching Case

A 78 years-old male patient with a history of chronic kidney disease due to right severe nephrolithiasis and subsequent homolateral renal atrophy, presented to the Emergency Department with abdominal discomfort and acute-on-chronic kidney failure.

Abdominal CT scan showed left hydronephrosis related to a suspicious malignant stenosis of the distal segment of the ureter. Therefore, urine cytology was performed, testing negative twice for tumour cells. Placement of a ureteral stent via ureteroscopy was unsuccessfully attempted. Hence, percutaneous nephrostomy was placed to reduce hydronephrosis and manage acute kidney failure. Subsequently, ureteral biopsy via ureteroscopic approach was attempted, but it was not feasible because of the technical difficulty to pass through the stricture. Therefore, we attempted to obtain a diagnostic specimen in the opposite direction through the nephrostomy tube; specifically, we performed fluoroscopic guided transluminal biopsy deploying biliary biopsy forceps, managing to obtain a diagnostic specimen for the histological exam, which revealed low grade papillary urothelial carcinoma.

Urothelial carcinoma represents 5% of ureteral malignancies and 10% of renal neoplasms.

The excellent visualization of the tumour provided by the ureteroscopic approach, along with the development of thinner and more flexible endoscopes, makes ureterorenoscopy the gold standard for the biopsy of the upper urinary tract [1]. However, it is an invasive procedure and, in some cases, it may prove difficult because of the impossibility for the endoscopic instruments to pass through the neoplastic stricture [2]. An effective alternative to this conventional method is fluoroscopic guided transluminal biopsy, already described in 1982 as one of the possible applications of the grasping forceps, using a percutaneous nephrostomy as access [3]. After this first report, to our knowledge, only another report describes this approach for a biopsy of the upper urinary tract. Interestingly, the same authors also described a similar approach being successfully used for two biopsies of the oesophagus, following the failure of conventional endoscopic methods to pass through the malignant stenosis [4]. As there are no specific instruments, the procedure was performed using a biliary biopsy forceps set (COOK, USA). This set is composed by a 7F sheath, capable of maintaining the forceps together with a 0.035" guidewire which, left across the lesion, provides stability to the system, enabling various specimens to be taken through the forceps.

In our opinion, this is a safe, effective and useful technique that should be taken into consideration when ureteral biopsy is required and ureterorenoscopy has proven ineffective.