title: Ureteroscopic biopsy of upper tract urothelial carcinoma using a novel ureteroscopic biopsy forceps.
abstract: BACKGROUND
  We sought to assess the adequacy of surgical specimens obtained utilizing the BIGopsy (Cook Medical, Bloomington, IN, USA) biopsy forceps both ex vivo and in vivo and compare them to traditional 3Fr biopsy forceps in patients with suspected upper tract urothelial carcinoma.
  
  
  METHODS
  Patients undergoing nephroureterectomy for suspected upper tract transitional cell carcinoma were recruited.  Surgical specimens, immediately after extirpation were examined and alternatively biopsied ex vivo with the BIGopsy and 3Fr biopsy forceps.  We then retrospectively reviewed our most recent experience with ureteroscopic biopsy.  The biopsy device, size, depth, grade, stage, pathologic diagnosis and subjective biopsy quality were assessed.
  
  
  RESULTS
  Three ex vivo nephroureterectomy specimens were evaluated.  The average biopsy size from the 3Fr biopsy forceps was 3.5 +/- 2.8 mm2 and for the BIGopsy was 31.2 +/- 34.6 mm2.  Subjectively, the BIGopsy specimens revealed less distortion and fragmentation and were easier to interpret by the pathologist.  Sixteen patients underwent 19 ureteroscopic procedures.  The mean size in maximal diameter (mm +/- SD) of the biopsies in each group were; 3Fr 1.2 +/- 0.4, BIGopsy 3.4 +/- 2.0, nitinol basket 4.9 +/- 4.0 and laser 11 +/- 8.5.  Lamina propria was identified in 3/13 (23%) biopsies with 3Fr biopsy forceps, 6/11 (55%) biopsies with the BIGopsy forceps, 6/8 (75%) biopsies with the nitinol basket and 2/2 (100%) biopsies with the holmium laser.  Six patients underwent biopsies with both the BIGopsy and 3Fr biopsy forceps.  A definitive diagnosis was made in 2/6 cases with the 3Fr biopsy forceps compared with all 6/6 cases with the BIGopsy biopsy forceps.  Grade and stage matched final surgical grade and stage in 3/3 cases biopsied with the BIGopsy.
  
  
  CONCLUSIONS
  For lesions with stalks, the holmium laser and basket biopsy provided larger specimens than either of the forceps.  For flat or sessile lesions, the BIGopsy biopsy forceps provided larger, deeper less distorted specimens than the 3Fr biopsy forceps and correlated well with ultimate grade and stage.  Improved biopsy quality may translate into improved ability to diagnose both benign and malignant ureteral and renal pelvic mucosal lesions endoscopically.
authors.affiliation: Department of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.
authors.forename: Shaun E L
authors.initials: SE
authors.lastname: Wason
authors.forename: John D
authors.initials: JD
authors.lastname: Seigne
authors.forename: Alan R
authors.initials: AR
authors.lastname: Schned
authors.forename: Vernon M
authors.initials: VM
authors.lastname: Pais
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle / Q000295:instrumentation* / Q000379:methods; D002295:Carcinoma, Transitional Cell / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery; D015331:Cohort Studies; D004867:Equipment Design; D004869:Equipment Safety; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D007680:Kidney Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D012189:Retrospective Studies; D014516:Ureteral Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery; D020709:Ureteroscopes; D018666:Ureteroscopy / Q000379:methods*