72 y/o male with painless macroscopic hematuria . Describe the images
These are static images of the axial, coronal and saggital views of a delayed phase abdominal CT
The most striking feature is the left UP fillings defect seen, bilateral kidney parenchyma appeears normal , there is no HUN , no other renal masses, contralateral kidney on these iamges appears intact
The bladder is full with thickening of the inferior wall of the bladder - can also be sediment
The rest of the ureter can not be visualised on these images
I would also like to asess the Liver, Chest bones for mets
What would you like to do next
- Cystoscopy TRO bladder mass
- Bilateral selective cytology + RPGs
- Risk stratify
- Decide on Managment strategy
- Kidney sparing
- RNU + template LND + single post op intravesical chemo - T2-T4 / N0-N2 = Platinum based Adj chemo
T3-T4 , N+ PDL1+ = Nivolumab/Pembro
65 y/o male with flank pain and microscopic hematuria
CT : Large right renal upper pole cyst with fillling defect in the pelvis
What is your diff diagnosis
Radiolucent Filling defects:
- UTUC
- Blood clot
- stone
- Sloughed papilla
- Fungus ball
- bowel gass
External compresison
Describe the Paris classification
Used to report on urine cytology
How do you do Selective cytology
Ureteral catheters are inserted and Barbotage with saline is done to increase detection to 91%
Brush biopsies can also be done but has increased risk of bleeding and perforation
UTUC Epidemiology , Presentation, Pathology , Etiology, Eval ( Dx), Treatment
DEPPER Stepwise ( all in summary)
Definition : Urothelial Carcinoma of the Upper tract
E: Similar to Bladder Ca with Lynch and Balkan nephropathy
P : Hematuria
Flank pain
Acute renal colic
Asymptomatic
Advanced disease
Abdo pain
LOW
Bone pain
What is the risk of Bladder recurrence after UTUC Rx
EAU = 29 %
Risk of contralateral UTUC after Rx 6
2- 6%
Risk Stratification of UTUC
Low risk UTUC
- LG cytology
- LG histology
- unifocal
- no invasion on CT
< 2cm
High risk UTUC
- HG cytology
- HG histo
- Local invasion
- Histological subtype
- multifocal
-> 2cm
- HUN
TNM staging
Ta - non invasive papillary Uca
Tis - carcinoma insitu
T1 - Invades subepithelial connective tissue
T2 - Invades muscularis
T3 - Invades beyond the muscularis into the peripelvic fat or renal parenchyma ( ureter) tumour invades beyond muscularis into perinephric fat
T4 - Into adjacent organs or through the kidney into perinephric fat
N1 - Single LN < 2cm
N2 - Multiple LN or LN > 2cm
M1 - Distant mets
What risk factors are different to bladder cancer
Balkan nephropathy
Lynch syndrome
Analgesic abuse - phenacetin
How can you make the diagnosis for UTUC
CT IVP 92% sens
MRU 72% sens
Cytology
URS —If urine cytology is indeterminate
Treatment for Low risk UTUC
NB! Pt must be able to follow up
- Ureteroscopy + laser ablation
- percutaneous acess and resection
- ureteral resection
- Chemo ablation - Mitomycin containing thermal gel ( UGN 101)
Mitomycin Hydrogel = UGN 101
Reverse polymer hydrogel = thick at cold temperatures and gel at body temperature an dissolves in liquid
Thus developed as a sustained release mitomycin
Response rate of= 58 %
Side effects = Stricture rate 41 %
Stricture mitigation off label advice = Steroids and treatment holiday at first suggesition of any narrowing usually seen by 3rd or 4th Rx
Stenting
Give limited dose as adjuvant Rx after laser ablation
If giving all 6 doses for residual tumours = place a NT
Who gets adjuvant chemo for UTUC
LEVEL 1 evidence
POUT phase III prospective RCT
4 cycles of CG combo within 90 days post RNU vs AS
Disease free surveilance at 3 yrs 71 % vs 50%
5yrs 63% vs 46 %
MFS improvement = 19%
Indication = UTUC pT2-T4 N0M0 or any N1-2M0 , PS =0-1
Exclusion = GFR < 30 , Distant mets, unresectable, concurrent MIBC, PS >-2
What aboutt NAC for UTUC
Neoadjuvant Chemotherapy for High-risk Localized Upper Tract Urothelial Carcinoma: Final Long-term Outcomes from a Phase 2 Clinical Trial and an Expanded Cohort
Aug 2025 _ European journal of urology
Pathologygical response rate of 63% in patients with high risk Utuc was treated with GC 4 cycles prior to definitive surgery and had RNU within 12 weeks after NAC
DFS and OS rates was similar to POUT at 5 yrs
But becase 60-85% of patients may be ineligibleible for adjuvant GC or even carbo -itcan be strongly recommendedmended
Survival outcomes of KSS vs RNU in Low risk disease
CSS and OS at 5-10 yrs has no significant difference
65 y/o male with flank pain and microscopic hematuria
CT : Large right renal upper pole cyst with fillling defect in the pelvis
Define High risk and low risk features
Low risk
- LG on cytology
- LG on biopsy
- Unifocal
- < 2cm
- No invasive features on CT
High risk
- HG on cytology
- HG on URS biopsy
- local invasion on CT
- Histological subtype
Weak criteria
-HUN
- multifocal
- Tumour > 2cm
Risk factors for UTUC
Smoking
Aromatic amines
Phenacetine
Arsenic
Aristolochic acid = Balkan nephropathy
Lynch syndrome
Radiation
Chronic infection ( UTIS, stones)
Cyclophosphamise
Risk for bladder cancer in patient with UTUC
Synchronous Bladder Ca = 17%
Synchronous UTUC ( bilat) = 1.6%
Bladder recurrence afterr Rx = 29%
UTUC contralat after Rx = 2-6%
What happens to the risk of bladder cancer if JJ stent was placed for URS in UTUC
Thus, while URS with biopsy (which often involves JJ stent placement) increases bladder recurrence risk, the guidelines do not specify an exact percentage increase in risk due to JJ stent placement alone
CT : Large right renal upper pole cyst with fillling defect in the pelvis
What is your diff diagnosis
How will you manage this patient.
- Cystoscopy
- Bilateral selective cytology + RPGs
- U&E prior to CT IVP
- Risk stratify
- Decide on Managment strategy
- Kidney sparing
- RNU + teplate LND + single post op intravesical chemo - T2-T4 / N0-N2 = Platinum based Adh chemo
T3-T4 , N+ PDL1+ = Nivolumab/Pembro
What are kidney sparing options
- Ureteroscopy + endoscopyic ablation using Holmium or thulium laser ( laser vaporisation or excision with irrigationn to clear fragments and close surveilance with repeat URS in 8 weeks
- Perc access - resection
- Ureteral resection ( segmenral/ distal ureterectomy ) + ureteroneocystostomy , end-end technique, ileal interposition, renal auto transplantationt
- Chemo ablation = Mitomycin containing thermal gel - UGN 101 instillations 6 weekly via uteral catheter, complete response rate = 58 %
Cx Ureteric strictures, UTIS, HU, Pain
You do a laparoscopic nephroureterectomy and the patient develops an air embolism.
How would that present
How do you manage it ?
Occurs when gas ( CO2) used for pneumoperitoneum enters thee venous circulation and travels to the heart, lungs and can obstruct blood flowow. Rare and life threatening
CVS :
- Sudden hypotension
- Tachhy
- CVS collapse
- Mill wheel murmur
Resp :
Sudden drop in end tidal CO2 ( earlies sign)
Hypoxia
Cyanosis
Pulm HPT
Monitorng changes
Decrease ETCO2
Decreased SpO2
Increased Pulm artery Pressurere
Rx : Stop Co2 insufflation
Release pneumoniamoperitoneum
Control bleeding vessels
Place pt in latereal decubutyrs + head down positionon ( Durant position) = traps air in the right atrium
Gice 100% O2
Aspirate air via CVC
Hemodynamic supportt - IV fluids, Vasopressors,CPR
Advanced Rx = Hyperbarric O2
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PUJo22
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LUTS2
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Pelvic Lipomatosis9
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Paeds CAKUT42
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NGB39
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UTUC36
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Paeds Onco9
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Paeds DSD16
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Paeds PUV3
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ED24
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RCC59
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Paeds Genitourinary abn ( Hypospadia/ UDT/DSD)14
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Infertility0
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Renal benign conditions ( RAS/ RAA/RVH)10
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Vasectomies3
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Adrenal0
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Benign renal masses (AML etc)0
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Infections : Schistosomiasis0
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Random - Suture material , blades etc0
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Radiation cystitis0
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Bladder Cancer53
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Paeds PBS25
