UTUC

Question 1

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

Answer 1

Radiolucent Filling defects:
- UTUC
- Blood clot
- stone
- Sloughed papilla
- Fungus ball
- bowel gass

External compresison

Question 2

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

Answer 2

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

Question 3

Risk factors for UTUC

Answer 3

Smoking
Aromatic amines
Phenacetine
Arsenic
Aristolochic acid = Balkan nephropathy
Lynch syndrome
Radiation
Chronic infection ( UTIS, stones)
Cyclophosphamise

Question 4

Risk for bladder cancer in patient with UTUC

Answer 4

Synchronous Bladder Ca = 17%
Synchronous UTUC ( bilat) = 1.6%

Bladder recurrence afterr Rx = 29%
UTUC contralat after Rx = 2-6%

Question 5

What happens to the risk of bladder cancer if JJ stent was placed for URS in UTUC

Answer 5

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

Question 6

CT : Large right renal upper pole cyst with fillling defect in the pelvis
What is your diff diagnosis
How will you manage this patient.

Answer 6

1. Cystoscopy
2. Bilateral selective cytology + RPGs
3. U&E prior to CT IVP
4. Risk stratify
5. Decide on Managment strategy
   - Kidney sparing
   - RNU + teplate LND + single post op intravesical chemo
6. T2-T4 / N0-N2 = Platinum based Adh chemo
   T3-T4 , N+ PDL1+ = Nivolumab/Pembro

Question 8

What are kidney sparing options

Answer 8

1. 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
2. Perc access - resection
3. Ureteral resection ( segmenral/ distal ureterectomy ) + ureteroneocystostomy , end-end technique, ileal interposition, renal auto transplantationt
4. Chemo ablation = Mitomycin containing thermal gel - UGN 101 instillations 6 weekly via uteral catheter, complete response rate = 58 %
   Cx Ureteric strictures, UTIS, HU, Pain

Question 9

You do a laparoscopic nephroureterectomy and the patient develops an air embolism.
How would that present
How do you manage it ?

Answer 9

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

Question 10

Describe cuff of bladder surgery and risk and benefit of each