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Sam Chang: Hello everyone. My name is Sam Chang. I am a Urologist in Nashville, Tennessee, and I work with Vanderbilt University. One of the great things about working at Vanderbilt is I get to work every day with some of the real leaders in urology. And fortunately today, we have one of those with us today. Dr. Ryan Hsi did his residency at the University of Washington, his fellowship at UCSF, with Dr. Marshall Stoller, and is now actually, an Associate Professor. Time flies, when you get promoted in 18 months, things go very, very quickly. But I am very fortunate to have Dr. Ryan Hsi focus on actually, percutaneous techniques and evaluation for upper tract tumors. I'm going to turn the program over to Ryan. Ryan, do you have some slides to share?

Ryan Hsi: Yeah. Thanks, Sam for the kind introduction. I do not have any disclosures for this talk. I think what we'll do is, we'll talk about some of the background information, and then Sam and I, we can talk about a couple of cases together.

When I think about antegrade approaches or percutaneous approaches, really the goals are the same as what we would do for retrograde approaches. Our goal is to obtain tissue and cytology. A second goal is to ablate, and resect, and treat, the visible tumor. The oncologic goals are the same.

A main advantage of the antegrade approach is that we can use larger instruments. Some have argued that potentially for upper tract tumors, we can get better grading, better staging. You can get occasionally some muscle in the specimen. The nephrostomy tube, or the externalized tube, can be used for a second look procedure, or to facilitate adjuvant topical therapy.

And, like the retrograde approach, the antegrade approach, really sometimes you need staged procedures because of the need to ... because of the large burden of the tumor, or to verify the complete treatment. In a similar fashion, we need to manage the patient's expectations. Finally, because it is a percutaneous approach, the bleeding and infection risk is a little bit higher. And although it's commonly considered, and we should consider it, in the case report setting, there have been descriptions of tumor seating in the percutaneous tract.

What I think about retrograde, versus antegrade approaches, is where do we put retrograde ureteroscopy? Well, it's best for low-volume ureteral or renal tumors. And for the antegrade approaches, we are thinking of larger volume tumors, we are thinking larger proximal ureteral tumors. We are also thinking about cases where the retrograde approach is not possible, whether it's a very steep, lower pole calyx, a long lower pole calyx, or in the setting of a urinary diversion.

Often, these decisions to do antegrade approaches are not done alone. We often work with our tumor board, or our oncologists, to make these decisions together. And I think we are seeing that increasingly, as care is becoming more coordinated. And these approaches are often weighed against these other treatment options. And so, in comparison to let's say, a nephroureterectomy, you would think about, for example, a patient with a solitary kidney or CKD with a urinary diversion, or large tumor burden, where you want to consider a nephron-sparing approach. Or, in someone with a lower urinary diversion where you want to obtain tissue to guide neoadjuvant chemotherapy. Or, someone who is a poor surgical risk for nephroureterectomy. And when thinking about retrograde ureteroscopy, we're thinking about potentially, a lower pole location that is disadvantageous for retrograde, maybe a larger tumor size, or in the setting of a urinary diversion.

There are three main techniques to treat the tumor. You could use a cold cup, a Bugbee. Remember, if you use monopolar cautery, you do need to switch your irrigant to water, from saline. You can also use a monopolar/bipolar resectoscope. And with the advent of a higher power, and lasers that have more flexible dynamic settings, we are more and more commonly using holmium or thulium laser now.

I think some of the challenges of antegrade approaches when I think about how to compare this, versus, let's say, a transurethral resection in a bladder, is that access matters. So when you think about the upper tract tumor, whether you go upper, lower, pole, mid pole, the posterior calyx, you really need to think about where your location matters. Not only to assess the tumor, but also you do not want to perk right onto the tumor.

So getting your own access is the best. And oftentimes these calyces can be difficult to reach, due to prior topical therapy, or there is scarring from prior lasering. So it can be more challenging than, let's say, a stone case.

You also want to think about the irrigation that you use. Not only because, if you are using monopolar, you want to use water over saline, but you want to also be careful.. think about tumor seeding. You want to think about enough irrigation, so you can see from the bleeding, but you also do not want to overdo it and increase the renal pelvis pressures, and/or increase the risk for infection.

Remember, in the kidney, especially the renal pelvis and the proximal ureter, walls are thin, so you worry about perforation. You also need to consider, are there any potential cells that might travel antegrade, towards the bladder?

So I'm going to stop there, Sam. Any thoughts or questions before I go to the cases?

Sam Chang: No, I think we'll go to the cases, and go over some thoughts, as you try to think about things.

Ryan Hsi: Okay. I did put this slide here, which is a trick that I think can help convert an antegrade case to a retrograde case, and that is in a setting of a urinary diversion. If you can not find the ureteral orifice retrograde, you can put a needle into the kidney, and under fluoroscopy, fish the wire down, find the wire, grab it in the bladder, or neobladder, or ileal conduit, pull it out, and now you have through and through access, and now you've converted an antegrade case to a retrograde case. And so, that is what I often try to do in patients with ileal conduits, or neobladders, with smaller upper tract tumors.

Sam Chang: So how do you position them, right on their side then? Because you can't go straight prone to-

Ryan Hsi: Right.

Sam Chang: Okay. So-

Ryan Hsi: Yeah.

Sam Chang: .. the lateral decubitus, or a...

Ryan Hsi: Yeah. Certainly, if you were going to do this, you could place them prone, split leg, so you have access to the urethra and the flank. Or, you can place them supine lithotomy with a little bump on the side, so part of their flank is exposed, and so you have access to their flank and the urethra.

Sam Chang: Okay. Okay. All right. But I'm thinking about also a conduit, how do you get access then to the stoma?

Ryan Hsi: Right. So, if there's a stoma, you really need to, you can either put them a little supine, or you put them flank.

Sam Chang: Okay.

Ryan Hsi: Or, I guess you could fish the wire down, and then reposition them.

Sam Chang: Okay.

Ryan Hsi: Some places will have interventional radiology, get the access down, and then they'll come back.

Sam Chang: I see. Okay. Great. So a good trick though. Thanks.

Ryan Hsi: So the first case is a 67-year-old male with high-grade T1, with CIS of the bladder. He had a cystectomy and neobladder. A very common scenario, five years later, on surveillance, there's a left upper tract filling defect. And the past medical history is as listed.

So this is the CT scan of the CT urogram.

Sam Chang: So Ryan, when I see this, the first thing I wonder about is, I want to know how good a function the patient has, in terms of renal function? Because the left side doesn't look so healthy, you got a fair size mass, so you go back and forth. I want to know how much function that kidney provides, or at least have a rough estimate before I go try to salvage that kidney.

Ryan Hsi: Right.

Sam Chang: On the pole side, with an orthotopic diversion, or any type of continent diversion, I want to try to maintain as much renal function as possible. So tell us what you did here.

Ryan Hsi: Yeah. In this patient, his renal function was borderline, 1.2, 1.3. I think the challenge here is, how do you get a biopsy? You need a tissue diagnosis.

Sam Chang: Right.

Ryan Hsi: And so I have tried, I've looked in. I've never been able to find a ureteral orifice in a neobladder. There are different types of chimneys, or afferent lenses, efferent lenses, but I've never been able to find a ureteral orifice. So in this case, what we did was, you can see the amount of hydronephrosis. The right side is chronically dilated, but what you see on the left side, you see that renal pelvis tumor.

Sam Chang: Yes.

Ryan Hsi: Under ultrasound, you can see the hydronephrosis very easily, and you can put a needle into that under ultrasound. Our goal was primarily a tissue diagnosis.

Sam Chang: Right.

Ryan Hsi: Because, we thought potentially, a nephroureterectomy. So we only dilated him with 13 French and attained some biopsies. We were below the 12th rib and left him with the nephrostomy tube. We couldn't get the wire down, because you could see the tumor really, right there, and it ended up being a high-grade disease.

Sam Chang: Good case. How about the next one?

Ryan Hsi: All right. So next, that's a very common scenario. The next case is a 65-year-old male, gross hematuria, worked up with a CT urogram. I had a bladder mass on the left lateral wall, which came back low-grade TA, and he also had a left upper tract, renal pelvis tumor. His past medical history is listed. This patient had a ureteroscopy performed retrograde, but they were unable to enter into the kidney, and they had cytology as atypical, and then he was referred to us.

This was retrograde. Sam, do you think a lot of people would stent and try again, or...

Sam Chang: For this case, I would... There's a little controversy regarding stenting, with not only upper tract but with lower tract disease. More recently, with invasive disease, and increasing the chance of upper tract. We already know that this person probably has something going on in the upper tract.

Ryan Hsi: Yeah.

Sam Chang: I personally would probably, I would try, because this is a referral, I would try it myself. If I can, I probably would stent, or try to stent, or then consider, if it looked really tight, then consider, hey, call you, Ryan, and say, try to do this antegrade. What would you do?

Ryan Hsi: Yeah. This patient was stented, and this was all done at the time of the TURBT. And so they found out it was a low grade later on. And so when you stent this patient, you do get some dilation of the ureter, and when you go back in, oftentimes, it doesn't dilate as much as you think, and you can see that upper tract filling defect. That's a very, very large burdenous tumor.

Sam Chang: Okay.

Ryan Hsi: And so we discussed it with the patient, and the patient elected to have an endoscopic approach. So what we did was similar to the other case. This patient, now, is in a supine position. You'll notice that the spine and the kidney are overlying, it's because the C-arm and the kidney and spine are aligned, so it's a little bit more supine towards a flank position.

So we've got the access in the mid pole. You can see the filling defect, just to the edge of the UPJ there, and then we've dilated the 30 French.

So this is a video we took, and we saw the tumor on a stock. And so we took a couple of bites with it, with the graspers, and we were able to de-bulk it. And then here we are switching the irrigation to water, and then we're cauterizing it. And after you cauterize it, the visualization just became normal.

This is what you can get out of that upper tract. It's quite a bit of volume, and it was low-grade disease, but we were able to also get muscle in the specimen, which we would not be able to do typically ureteroscopically.

Sam Chang: No. No. Absolutely.

Ryan Hsi: Not retrograde.

Sam Chang: Yeah. I mean, I think you did this patient quite a service, in terms of low-grade disease. If it was allowed to continue, it probably would continue to obstruct that left kidney. But I would do everything I can to try and preserve this renal unit, at this point, based upon what you found. So, impressive. What do you do now in follow-up?

Ryan Hsi: So what we did in this patient was... Depending on their proximity, sometimes these patients travel quite a distance, and we often will recommend a ureteroscopy about six to eight weeks later, as a second look. Or, some patients may choose to do a CT urogram, knowing that it's less sensitive.

Sam Chang: And how long do you leave the nephrostomy tube in?

Ryan Hsi: I don't remember for this patient, how long we left it in. If we would have, it would have been overnight, or we leave the stent in.

Sam Chang: Okay. What about the last case, Ryan?

Ryan Hsi: The last case is an interesting one. I present it just to show you the breadth of the types of cases. So, an 81-year-old male, with intermittent gross hematuria. This patient had known high-grade upper tract disease in the left renal pelvis that was managed ureteroscopically but he also had metastatic disease. This patient had very bothersome symptoms from the hematuria, and he had multidisciplinary conferences and was working closely with oncologists. They desired palliation because they felt that would improve his quality of life. I think there was a very interesting narrow indication for this, but we counseled him about what that would involve.

His tumor, you can see here, in the mid pole, you can see that filling defect on the retrograde?

Sam Chang: Yes.

Ryan Hsi: And the upper pole you do not see because it was previously scarred. The previous ureteroscopy showed that there was no disease in that area, but quite a large burden tumor, that you otherwise, probably couldn't really manage symptomatically retrograde.

Sam Chang: Okay.

Ryan Hsi: I don't have the video from this, but what we did was, we did a lower pole puncture. We went in, just like the other cases, on a stock. We were able to resect all the way down to the base, and filtrate it, and left the nephrostomy tube in.

Sam Chang: Wow. Well, Ryan, as you unshare your screen, in terms of key take-home messages for people, as they try to determine the whole percutaneous antegrade, versus ureteroscopy, you gave a breakdown of smaller lesions, easier, in terms of accessibility. You go retrograde, larger lesions, et cetera, you go antegrade. Are there times where you really think that you should not go antegrade? When are times where you would avoid an antegrade approach?

Ryan Hsi: I think we should take a pause in certain situations. Any time you know someone is high grade, or you have a very high suspicion that person is high grade, you should take a pause. Especially, due to the risk of tumor seeding.

If the tumor is multifocal, or you haven't had a really good mapping of where all the tumors are, I think you should take a pause, because you don't want to gain percutaneous access into a calyx that you don't want to be in. I think the standard rules apply for any time you consider percutaneous access. If they can't come off of anticoagulation, or if they, some patients have barren anatomy where they have bad retrorenal bowel, or they have some vascular vessels behind the kidney, you certainly wouldn't want to do percutaneous access, through there.

Sam Chang: Go ahead.

Ryan Hsi: I'd also just mention that a lot of you will say that retrograde ureteroscopy for upper tract tumors never goes as well as you think. And it is also because mobility is difficult, and your instruments are limited. And I think for antegrade ureteroscopy, your mobility is better, but also, sometimes the visualization can be tricky. And I think you need to just go in, be patient, and manage the patient's expectations, but just understand, they can be challenging. These tumors can be very vascular.

Sam Chang: Well, that's why, fortunately, I've got partners like you, because these procedures are not easy, but they really do offer an opportunity for our patients to do something that could be nephron-sparing, and be able to take care of their symptoms, and many times be able to take care of their disease.

I want to thank you, Ryan, for taking some time and enlightening us regarding your techniques, and what you are able to do, and I look forward to referring to you even more patients in the near future. So thanks again. Appreciate it very much.

Ryan Hsi: Thank you for the opportunity.