There are many components to Urologic education, but one which we feel is missing from the text books is a practical guide to Urologic procedures. In this surgical atlas, we review the management of surgical patients from before they enter the operating room to after they leave. We highlight key points of their pre- and post-operative care, underscore details which medical students or residents are likely to be asked in the OR, and present a multi-media atlas for step-by-step guidance through each procedure. By providing these features, we hope to make UrologyMatch an important reference source in this new era of surgical education.
ANATOMY OF THE PROSTATE
Detailed understanding of prostatic anatomy is essential for every
urologist.
Figure 1: Prostate Anatomy
PS=pubic symphisis AFS=anterior fibromuscular stroma SV=seminal
vesicle CZ, TZ, PZ=zones of prostate (see text)
Figure 2: Cystoscopic view of lateral lobes.
Edge of the verumontanum is seen at 6 o'clock.
Figure 3: Cystoscopic view of a large median lobe.
The ball-valve obstruction created by a median lobe in some men is clearly
appreciated from this image.
Grades
You needed good grades to get into college and good grades to get into medical school--getting into residency is no different. Grades in the first two years are important, but residency directors care much more about clinical clerkship performance. Strong grades in Core Surgery and Core Medicine clerkships are very desirable. A high grade in your Urology sub-intership(s) is extremely helpful. Beyond these specific clerkships, it is your overall pattern of grades that will stand out. What's most coveted, not surprisingly, is AOA, as this gives the residency admission committee the best evidence that you are among the top of your class. You can absolutely still match without being AOA, but it will be more difficult to match at top programs. Some top medical schools do not have AOA chapters, and ERAS allows you to select "No AOA Chapter At My School" option on the application. Bottom line: if you think your grades are marginal, you should find a good advisor to council you on where you stand.
Board Scores
Board scores are extremely important. They provide the most objective comparison of applicants and play a significant role in the selection of candidates for interviews. You will find that once you have made it to the interview round, these scores begin to carry significantly less weight. Here is a rough breakdown of scores:
< 215 - seek advice on whether you have a reasonable chance at matching; people do match with these scores, but only with a very solid application.
215-230 - your score may hurt you in the eyes of many programs, but many people match every year with these scores.
230-240 - these are solid scores and you should certainly do fine. If you are aiming for top-tier programs, however, this is hopefully not the strongest part of your application.
240-250 - you are in great shape.
>250 - your board score is outstanding and will stand out.
Having USMLE Step 2 on your application is not at all necessary, but if you believe that your score on Step 1 is marginal, doing well on Step 2 can be a very strong move. The best advice is to take Step 2 after you submitted your ERAS application and all the schools have downloaded your USMLE score report (early November is perfect). Be sure that you do NOT select "automatic score reporting" when filling out the application. This way, if your Step 2 scores are high, you can instruct ERAS to release them to the residency programs in time to help you. If you do no better on Step 2 than on Step 1, do not release your scores and no one finds out. Every year we see applicants who apply with excellent Step 1 scores and poor Step 2 scores--these students have completely unnecessarily severely damaged their application. Note, recently the UCSF program (see details) has announced a requirement that students must have Step 2 scores submitted prior to being ranked.
Benign Prostatic Hyperplasia (BPH) and Its Treatment
Surgical Therapy (Thermal therapy, Laser prostatectomy , TURP , Open Prostatectomy)
Pathophysiology:


Figure 4: Resection with electrocautery loop during TURP.
Figure 3: Delivery of enucleated lateral and median lobes during an open prostatectomy in a patient with a ~250 g gland. Another lateral lobe is yet to be enucleated.
The link below will open a document in a new window:
Laparoscopic Fundamentals from the AUA
Click the link below to open AUAnet.org document in a new window.
GU Pathology from the AUA
Bladder Stone Treatment
I will not cut for stone, even for patients in whom the disease is manifest;
I will leave this operation to be performed by practitioners.
-Hippocratic Oath
Before the advent of modern surgical techniques, treatment of bladder stones was a very risky venture. The most common approach to removing bladder stones, known as lithotomy, involved removal of the stone through a perineal incision in an awake patient after a metal sound was placed through the urethra to secure the stone's position in the inferior portion of bladder. Indeed, Hippocrates considered the procedure so risky that in his oath he advised that only the skilled professional attempt the feat. Some believe that Hippocrates' recommendation is the first designation of a surgical subspecialty.
Urinary stasis (whether from bladder outlet obstruction or neurogenic dysfunction), infection, and presence of a foreign body are the primary culprits for bladder stone formation.
Classic "jack" stone in an elderly patient with bladder outlet obstruction (click to watch video)
Modern surgical armamentarium for treatment of bladder stones includes open surgery (suprapubic approach), manual cystoscopic lithalopaxy (crushing of stone with forecepts), ultrasonic lithotripsy, pneumatic lithotripsy, electrodydralulic lithotripsy (EHL), holmium:YAG laser, and rarely extracorporeal shock wave lithotripsy.
Surgical Tips:
Radical Orchiectomy
Pre-Operative considerations:
1. Verify side of tumor - have imaging in the room
2. Make sure tumor markers have been drawn
3. Examine patient thoroughly prior to making incision -- this will help develop your testicular exam skills and verify side of tumor
*When performing testicular examination (in any setting), convince yourself that you are able to palpate (1) testicle proper, (2) epididymis, and (3) cord
4. A single dose of a second generation cephalosporin is appropriate prior to making incision.
Intra-Operative considerations
1. In supine position, lower abdomen, genitalia, and perineum are shaved, prepped, and draped
2. Incision is made over the inguinal ligament similar to an inguinal herniorrhaphy. Landmarks are the anterior superior iliac spine and the pubic symphisis (marked on image below)

3. Electrocautery is used to divide the subcutaneous fat and expose the external oblique fascia
4. The fat is bluntly cleaned off the fascia for better exposure, typically using a sponge and/or retractors (spreading down to fascia with two band retractors works very well)

5. Using a scalpel, a small incision is made in the external oblique fascia in line with the muscle fibers
6. Metzenbaum scissors are used to extend the fascial incision all the way to the external ring as well as in the opposite direction (toward internal ring)
a. Care is taken to first spread open the scissors underneath the fascia to clear off the ilioinguinal nerve
b. The nerve can often now be identified and set aside by placing a hemostat on the lateral edge of the fascia with the nerve lateral to the hemostat
c. Some may find tagging the medial and lateral fascial edges with suture useful to expedite closure later
d. It is important to open the external ring completely, dividing all of the fascial fibers -- this will faciliate delivery of the testis later

7. Grasping the edges of the fascia, the cord is bluntly dissected free
8. The cord is then encircled, often first with a finger (tease the cord off the pubic symphisis with thumb and finger) and then a Penrose drain is pulled through to fully retract the cord.
9. The Penrose drain is then wrapped a second time around the cord and clamped to completely constrict the cord
a. The theoretical goal is to prevent hematogenous micrometastases from being sent into the circulation during tumor manipulation
10. The testis is then delivered into the wound by pulling on the cord and pushing on the testis (it you find this step difficult, you did not divide all the necessary fibers of the external ring). Fascial attachments preventing delivery of the testis into the wound may need to be freed. One must be very careful not to violate scrotal skin. Blunt dissection with a surgical sponge to peel off the testicle from scrotal skin is very useful here (image below).

11. The gubernaculums is then clamped, divided and ligated. Again be absolutely sure you are not button-holing the scrotal skin (note how the scrotal skin in inverted into the wound on the image below -- if you violate the scrotal skin, you upstage the tumor and may change post-operative management!)

12. Attention is then turned to the superior portion of the cord and vas, which are separately clamped and divided as high as possible above where the Penrose was placed.
a. Ligation is typically performed with 2-0 silk or proline free ties and a suture ligature. Leave one suture long, so you can find it at RPLND.
b. It is important to drop the cord into the internal ring/retroperitoneum in order to faciliate cord removal at RPLND.
c. Be sure your ligation is secure -- bleeding into the retroperitoneum from a poorly secured testicular artery can be life-threatening.

13. Electrocautery is used to obtain hemostasis, careful attention needs to be paid to the scrotum to prevent hematoma formation
14. The external oblique fascia is then closed followed by the subcutaneous fat and the skin
15. A sterile dressing as well as fluffs and a scrotal support are then typically applied.
1. Monitor patient for scrotal hematoma and retroperitoneal bleeding
2. Markers must be rechecked during a post-operative visit in ~ 4 weeks (remember T1/2 for AFP = ~5 days and for HCG = ~48 hours)
Simple Orchiectomy
1) In supine position, lower abdomen, genitalia, and perineum are prepped and draped
2) If bilateral orchiectomy, median raphe incision is made. If unilateral, can perform either median raphe or transverse hemiscrotal incision.
a. Skin traction is important when making scrotal incisions due to tissue laxity
3) Electrocautery is used to dissect through the dartos muscle and cremasteric fibers in order to expose the tunica vaginalis
4) A sponge is used to push the fibers off of the tunica vaginalis and fully deliver the testis/tunica vaginalis through the wound
5) Continue to use a sponge to clean off the tunica vaginalis such that it is fully exposed
6) Incise the tunica and expose the testis
7) With traction on the testis to expose the cord, bluntly dissect the cord into 2 or 3 segments. The vas is typically isolated in its own segment. Clamp, cut, and ligate each segment, typically with 2-0 silk. A suture ligature is often used due to risk of bleeding from the cord and the fact that it will quickly retract up into the pelvis once it is released.
8) Irrigate the wound and liberally electrocoagulate possible bleeders due to risk of scrotal hematoma
9) Close the dartos in a running layer and then the skin.
10) The wound is typically dressed with bacitracin, fluffs, and scrotal support.

Medtronic InterStim Therapy for urinary control has been shown to successfully treat certain bladder control problems in patients for whom more conservative treatments were unsuccessful. InterStim Therapy addresses the nerve component of bladder control problems by sending mild electrical pulses to the sacral nerve which influences the bladder and surrounding muscles that manage urinary function.
InterStim Therapy for is indicated for the treatment of non-obstructive urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. It is not indicated for mechanical obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture.
Patients must undergo a trial assessment period, known as Peripheral Nerve Evaluation (PNE). Through a simple, in-office procedure, the physician places a temporary lead that is connected to a small external test stimulator. The trial assessment allows the patient to experience the effects of the therapy for approximately 3-7 days to help the patient and physician determine if long-term therapy will be beneficial.
Peripheral Nerve Evaluation Procedure
Note: Complications can occur with the trial assessment, including movement of the wire, technical problems with the device, and some temporary pain.
If the PNE test is inconclusive or unsuccessful, a chronic lead test is recommended. This test utilizes a tined (chronic) lead, to reduce migration. Placement of the tined lead is performed through an outpatient procedure and is connected to the same external stimulator. With conclusive test results, this lead can remain in place and the implantable neurostimulator (INS) and lead extension would then be implanted.
Placement of the Permanent InterStim Tined Lead and Implantable Neurostimulator (INS)
Patient-reported results will allow the physician and the patient to make an informed choice regarding the long-term therapeutic success of the therapy. Permanent implantation of the InterStim tined lead and INS is performed after a successful PNE or chronic lead test.
Physician training is required prior to implantation of InterStim components and the product technical manual must be reviewed for detailed, step-by-step instructions of the implant procedure. A summary of the InterStim II device implant procedure is presented below:
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Using bony topography or fluoroscopy as a guide, |
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Stimulation is applied to confirm appropriate |
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Once position of the foramen needle is |
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A small incision is made on either side of the |
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The tined lead is placed into the introducer and |
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Once appropriate placement of the lead is |
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The lead is connected to the INS header. |
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The INS is placed in the subcutaneous pocket |
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Pocket is closed.
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For additional information on InterStim Therapy and educational opportunities, visit http://professional.medtronic.com/sns
InterStim® Therapy for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments.
Contraindications: Diathermy. Patients who have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator.
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Warning: This therapy is not intended for patients with mechanical
obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture. |
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Precautions/Adverse Events:
Safety and effectiveness have not been established for bilateral stimulation; pregnancy, unborn fetus, and delivery; pediatric use under the age of 16; or for patients with neurological disease origins such as multiple sclerosis. The system may be affected by or adversely affect cardiac devices, electrocautery, defibrillators, ultrasonic equipment, radiation therapy, MRI, theft detectors/ screening devices. Adverse events include pain at the implant sites, new pain, lead migration, infection, technical or device problems, adverse change in bowel or voiding function, and undesirable stimulation or sensations, including jolting or shock sensations. For full prescribing information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic’s website at www.medtronic.com. Product technical manual must be reviewed prior to use for detailed disclosure.
USA Rx Only. Rev 0409
Flexible Ureteroscopy
Principles:
Wire review:
There are numerous different types of wires which are used in Urologic procedures reflecting the many different ways in which wires are utilized. Their most common functions are to: a) gain access to the ureter, and b) act as the inner component of a coaxial system allowing stents, catheters, and other working devices to be safely passed into the collecting system. The basic characteristics of interest which differ among wires are flexibility, lubricity, and shaft stiffness. Wire diameters typically range from 0.018 to 0.038 inches, with 0.035 and 0.038 wires used most frequently. The tips are often made flexible in order to minimize ureteral trauma.Here, we review the most commonly used wires.
Ureteral access and pyeloscopy:
The double floppy tip wire is used to pass the ureteroscope. The flexible ureteroscope is passed under fluoroscopic guidance over the wire all the way up to the renal pelvis (unless there is a ureteral stone or stricture blocking its path)
Laser lithotripsy:
Post-op management:
Transitional cell carcinoma of the upper urinary tract (ureter and/or renal pelvis) accounts for approximately 2-5% of all urothelial carcinomas. Traditionally, management of these lesions has consisted of open or laparoscopic nephroureterectomy with a bladder cuff or, if the lesion is distal, a distal ureterectomy with a bladder cuff and ureteral reimplantation. This surgical approach to UTUC yielded a 45-90% cancer-specific survival at 5 years; 10-30% of these patients developed metastatic disease. With the introduction of ureteroscopes and percutaneous techniques in the early 1980s and their continued technological improvements, direct visualization and treatment of an upper urinary tract urothelial tumor is now possible and efficient. Historically, endoscopic management of UTUC was reserved for patients with bilateral disease, a solitary kidney, chronic kidney disease (CKD), or significant co-morbidities that would preclude a major abdominal operation (Note: These indications are almost identical for the widespread adoption of partial nephrectomy for renal tumors). Rendering a patient functionally or anatomically anephric is fraught with significant health risks, thus endoscopic management was employed. One study cites the 5-year overall survival range for patients aged 55-84 with end-stage renal disease as 10-32%.
As endoscopic management for UTUCs have became technically feasible for patients with absolute indications, data began to mature that showed equivalent 5-year cancer-specific and overall survival between patients treated with endoscopic, nephron-sparing approaches versus traditional extirpative management. Table 1 is a synopsis of the most recent studies comparing open versus endoscopic management of UTUC. In sum, these studies show that endoscopic management of UTUC has equivalent overall, cancer-specific, and metastatic-free survivals to traditional management for low-grade and low-stage UTUC tumors. Patients who undergo endoscopic management do have a higher local recurrence rate (20-85%) and are subject to more procedures for long-term surveillance. Most practioners are unwilling to subject patients with high-grade UTUC to endoscopic management unless absolute indications exist; as of yet, there is no data to support the use of endoscopic management for high-grade disease.
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Series (year) |
# of renal units |
Median/mean follow-up (months) |
Treatment (Ntx-u v. Endoscopic) |
5-year survival (Low-grade v. high grade) |
5-year survival (Ntx-u v. Endoscopic) |
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Wolf et al. (2010) |
96 |
76.9 |
62 v. 34 |
OS: 73.0% v. 43.0% CSS: 94.0% v. 75.0% MFS: 91.0% v.67.0%
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OS*: 47.8-71.8% v. 25.0-74.8% CSS: 72.4-89.2% v. 85.7-100.0% MFS: 63.5-87.8% v. 85.7-94.4%
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Lucas et al. (2008) |
120 |
45.8 |
79 v. 41 |
OS**: 66.4-75.4% v. 45.0-71.5% CSS: 86.2-87.4% v. 68.6-75.0% RFS: NR |
OS: 72.1% v. 61.7% CSS: 83.0% v. 81.6% RFS: NR |
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Roupret et al. (2006) |
97 |
51.5-60.0 |
54 v. 43 |
OS: NR CSS: 81.9% v. 47.3% MFS: NR |
OS: NR CSS: 84.0% v. 80.7% RFS: 75.3% v.71.5% |
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Sowter et al.^ (2007) |
41 |
41.6 |
Endoscopic management only |
n/a |
OS: 80% CSS: 100.0% Recurrence rate: 74.3% |
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Krambeck et al. (2007) |
37 |
2.9 yrs |
Endoscopic management only |
n/a |
OS: NR CSS: 49.3% RFS: 27.1% |
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Elliott et al. (2001) |
21 |
6.1 yrs |
Endoscopic management only |
OS^^: 66.0% CS: 100.0% Recurrence rate: 25-46% |
n/a |
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* Ranges indicate difference between low-grade and high-grade disease ** Treatment modality grouped together when examining survival of low-grade tumors versus high-grade tumors ^ Endoscopic management only ^^ Low-grade tumors only |
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Table 1. Comparison of series employing endoscopic treatment of UTTCC as primary management strategy
II.Technique
Diagnostic ureteroscopy is employed as the first-line treatment for evaluation of a filling defect seen on CT urography, intravenous urography, or retrograde ureteropyelography. A distal lesion can be accessed with a semi-rigid ureteroscope while a lesion in the proximal ureter or renal collecting system is best approached with a flexible ureteroscope. The method for ureteral access is similar to the technique employed for ureteroscopy for stone disease (see Surgical Procedures Atlas VIII).
A brief step-wise approach to ureteroscopic evaluation and management of upper urinary tract urothelial carcinomas is presented below:
1. A wire is placed into the desired kidney under fluoroscopic and cystoscopic guidance (Fig1). The choice of wire is at the discretion of the operating urologist; we use a 0.038 Guidewire. (See review of wires under ureteroscopy Atlas.) During this portion of the procedure, take care to perform a thorough cystoscopic examination of the bladder as a bladder lesion will develop in 23-75% of patients with an UTUC.
Figure 1: Placement of initial wire
2. We then insert a dual-lumen access catheter over the existing wire (Fig 2) into the ureter for two reasons: the dual-lumen catheter passively dilates the distal ureter and we can obtain a selective cytology from the interested side and then place a second wire (0.038 Guidewire) without losing access to the kidney (Fig 3).
Figure 2: Placement of 2nd wire
3. Once we have cytology, we then perform another retrograde pyelogram to outline the collecting system (Fig 4).
Figure 4: Retrograde Pyelogram (make sure cytology
has been obtained prior to injection of dye)
4. For renal pelvic and/or calyceal lesions, we then advance the flexible ureteroscope under fluoroscopic guidance up into the renal pelvis over one of the Guidewires (Fig 5). Once the ureteroscope is in good position, the Guidewire is removed and the second wire is used as a safety wire.
Figure 5: Advancement of ureteroscope under
fluoroscopic guidance.
4a. Sometimes you may have trouble traversing the distal ureter with the flexible ureteroscope. Rather than using a balloon dilator to dilate the distal ureter, we have found that leaving the cystoscopic sheath in the bladder and using it to provide backing as you try to navigate the distal ureter is a helpful means to circumnavigate this potential impediment. If you are ever in doubt or cannot bypass the distal ureter, simply leave a JJ stent and return for your diagnostic ureteroscopy in 1-2 weeks.
5. Once you have the ureteroscope in the renal pelvis (Fig 6), you can perform a thorough upper tract endoscopic examination, using fluoroscopy as an aid in accessing difficult calyces.
6. If you find a papillary lesion, obtain a repeat cytology with the ureteroscope directed at the lesion. Then obtain multiple biopsies of the lesion with either a flat-wire basket or a 3 Fr. ureteroscopic biopsy forceps.
7. Remember, grade correlates with stage. In multiple series, low-grade tumors correlated with Ta or T1 disease in 86.6-100.0% of cases. Similarly, high-grade tumors correlated with invasive TCC in 66.7-96.0% of cases. Thus, a low-grade lesion is going to be superficial and should be treated endoscopically. This may require multiple endoscopic treatments, however this is preferable in light of renal preservation.
8. Once you have sufficient biopsies, the tumor then can be treated with either the Nd:YAG and/or Ho:YAG laser or a ureteroscopic Bugbee. See Surgical Atlas VIII for a brief review of lasers. In brief, Nd:YAG laser has a greater depth of penetration (4-6 mm) and can be used to coagulate the tumor. The Nd:YAG laser does not need to touch the tumor for effect. The Ho:YAG laser has a shallower depth of penetration (less than 0.5 mm) and can be used to ablate the tumor deeper.
9. These are the recommended fibers and settings for each laser:
a. 200 um or 365 um fiber
b. Nd:YAG: 30W
c. Ho:YAG: 1J and 10Hz
10. In general, it is best to use the Nd:YAG laser first to coagulate the superficial portion of the tumor. This laser’s depth of penetration is not as precise as the Ho:YAG, so care must be taken when treating the deeper portions of the tumor. The Nd:YAG laser can perforate the ureter or the renal pelvis. When ablating large lesions, it is helpful to begin ablation at the more proximal portion of the tissue and then work distally. This hopefully helps to avoid advancing the fiber into the mucosa or wall of the ureter or renal pelvis.
11. The Ho:YAG laser can then be used to ablate the deeper aspects of the tumor and detach the tumor from the underlying parenchyma/urothelium. The Ho:YAG laser must be in direct or close contact of the tumor in order to treat the lesion.
12. For difficult to access calyceal tumors, a 2 Fr. Bugbee electrocautery probe can be used to fulgurate a lesion. The smaller probe allows for more ureteroscopic deflection in order to treat the difficult to access lesion. When using the Bugbee electrocautery, fulgurate on the cutting mode. This theoretically reduces the chance of an ureteral stricture or infundibular stenosis.
13. Once tumor treatment is complete, the decision to leave a temporary ureteral stent is left to the treating urologist. Nevertheless, there are few disadvantages to inserting a JJ stent in this setting.
14. Percutaneous resection of UTUC is generally reserved for tumors larger than 1.5 cm or bulky proximal ureteral tumors. The technique for this approach is very similar to a percutaneous approach for stone management (PCNL). Once intrarenal access has been obtained, a cystoscopic resectoscope can be used to remove the tumor followed by deep laser ablation.
The most common technical complications associated with endoscopic management of UTUC are similar to those seen with any upper tract endoscopic intervention: ureteral perforation and ureteral stricture. Reported rates of ureteral perforation and ureteral stricture are 1-4% and 9-12%. Not all ureteral strictures are due to technical considerations and biopsy of the stricture must be performed to rule out recurrent disease.
1.Bagley DH and Grasso M. Ureteroscopic laser treatment of upper urinary tract neoplasms. World Journal of Urology. 28: 143-9, 2010.
2. Soderdahl DW et al. Endoscopic treatment of upper tract transitional cell carcinoma. Urologic Oncology. 23: 114-22, 2010.
This page was written for UrologyMatch.com by Daniel J. Canter, MD

Dr. Canter is a graduate of the University of Pennsylvania Urology Residency Program.
He is currently a Society of Urologic Oncology Fellow at Fox Chase Cancer Center.