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Good evening guys. Thanks for tuning in. Uh We'll start very shortly. Um Thanks very much for agreeing to come to this um, last session of this particular set of sessions. Uh I need some more time to make a few more if we are able to do that. Um Today's topic will be on something a bit less well known about or well taught about in medical schools, but nevertheless, just as important, um given the prevalence of the condition and um importance of the condition, uh which is upper urothelial tract cancers, it's now 730. Um, we've got a fair few people here so we'll just let everybody else join as we're going through just to make sure, uh can everyone hear me and see my screen? Just let me know in the chat and lovely, lovely, cool. Let's go. So this next session up here if you do attract cancer and it's surgical management, um I genuinely think this is more um poorly understood, er, than other forms of cancer, including um, by a lot of surgical trainees just because it's not very common and it's not very well taught about. Um, nevertheless, you will come across it, um, fairly regularly, especially if you end up doing urology. But you'll come across, um, this condition in some way, shape or form, even if it's, um, not actually cancer but a lesion that may be cancer incidentally on a scan. Um, er, or, or in other walks of life. So, it's important to, er, learn about it. Nevertheless, um, we're gonna talk about how, er, these tumors may present, understand the investigations, um that are best for this condition, how surgery can use for both diagnosis and management and understand how these patients are followed up and the complications they may experience. Um I think this talk is quite good surgically. And part of the reason for that is because um the procedures involved um initially for some of its investigation um can be something you learn earlier on in your training than for example, a lot of the complex robotic stuff that you might see. Um that being said. So the radical treatment is, is very complicated. So that's not what you'll see necessarily fer further on. But um, you'll understand more as we go along, why this is something that, er, you can get involved with surgically pretty early on in training, er, compared to a lot of stuff malignancy within uh the lining of the renal calices, pelvis, uh the ureters and the ureteric orifice counts as cancer of the upper urothelial tract. And so by which, I mean, I, you know, the kidneys the ureters, ureteric, um distal ureter and the ureteric orifices. Whereas the lower urinary tract is the bladder and urethra. Um And um to less in men can include the prostate as well. Um This is relatively rare and because of its sort of wide area of the body that it can affect, it can be split into renal pelvic, pelvic caliceal and ureteric disease. Um because although they all form part of the upper urothelial tract, you can appreciate the differences between those sections. They're almost always transitional cell carcinoma and ct urogram is often the initial gold standard. Um er, investigation of choice, er for diagnosis. Er, many patients will require ureteroscopy and biopsy. Um and there are kidney sparing um but also non kidney sparing radical treatments for er, this condition. It represents about 5 to 10% of ethel cancers and 10% of all renal tumors with the most common type of renal tumor being renal cell carcinoma, RCC. And of course, the most common type of urothelial cancer being bladder cancer. Um So it's a rarity in, in both of its sort of anatomical sites. Um rare, you know, very rare, two per 100,000 person years in terms of its estimated incident. Um um and much like bladder cancer, it tends to affect the older population with the peak ages occurring um within the seventies. Uh and between age 17 and 19, most patients er present with non muscle invasive disease. So, m I DD, non muscle invasive. So that's PT one or below and 50 to 60% are present with muscle invasive disease. Um So the more advanced forms of the disease, 25% present with metastasis. And that's partially due to the lack of symptoms that patients may actually present with. Um and so they may present late in their disease course, 17% or so of patients with upper tract disease will also have bladder cancer. Uh and that fits in with the multifocal er aspect of bladder cancer that we spoke about two weeks ago. Um because that's a condition that doesn't just occur necessarily in one section of the bladder. It can do but not necessarily, it can occur in multi sites within the bladder. And given that the urothelium in the ureter is a continuum with the is in continuum with the bladder. It makes sense that it can occur in both the upper and lower tract simultaneously or at different times throughout patient's life. Those with bladder cancer or carcinoma in situ are more likely to develop er upper tract TCC than those developing upper tract TCC. Um as a single disease. Many of these T CCS also come from the bladder rather than the other way around. So, it's bladder cancer seeding upwards rather than ureteric cancer seeding downwards. Patients with upper tract TCST CCS are also at higher risk of bladder cancer recurrence. Um So those with, with upper tract TCC and bladder cancer are more likely to have bladder cancer again, uh in their lifetime than those without the upper tract disease. As I say, over 90% are, er, of, er, arac T CCS, er, upper tract tumors are T CCS. Er, but other cancers can include squamous cell carcinomas and adenocarcinomas as well. I've mentioned it's inherently multifocal er, and the image er, on the right hand side of the screen kind of IMA er demonstrates the kind of ways it can present er in terms of its anatomy. It can occur due to a single cell spreading throughout the urothelium or multiple independent tumors, which are all affected by something in the environment that causes cancer. Um for example, smoking or exposure to various things or genetic effects. Um so it can be, you know, two mechanisms of action um are sort of posited in the literature. Spread can occur within the lumen of the ureter or between epithelial cells. Um and the morphology of these T CCS are similar to what we see in bladder cancer as well. 25% have some variation in their histology. Um so much like in prostate cancer, there can be variation in the Gleason score. So too can you have variation in the histology of these ureteric cancers which may represent the multifocality of it? Um Some, for example, have features of SEC despite being mainly TCC S CCS can exist independently of T CCS er and occur in 1 to 7% of all patients with upper tract urothelial cancers. Other rare forms include the neuroendocrine and sarcomas that can occur. Benign lesions of the upper tract also exist. So that's why it's important to er, think about how these look different and how these may present differently and how the patients who may or may not have malignant disease may be investigated differently to those with strong evidence of malignant disease. Um for example, fibro epithelial adenomas um are an example of a benign lesion um within the upper tract that can occur. And I have for example, been in theater er, where a patient has quite an odd looking um tumor when we were doing a ureteroscopy looking inside the ureter took a biopsy, it ended up being benign. Um So that was obviously good news for that patient for moving on just some definitions. Um So a synchronous tumor er occurs when you have multiple cancers existing at the time of diagnosis. Whereas a metachronous tumor er occurs when you have tumors that develop one after the other. Um and so that's important in the context of this but also things like bowel cancer er, as well, risk factors um includes, we've mentioned age but male gender, it's almost twice as common in men compared to women. That's uh you know, smoking as well increase the risk by 7.2 times uh previous bladder cancer. Uh and so, and, and chronic bacterial infections which increase the risk of sec, those, those are exactly the same as in bladder cancer. But we also know that there are genetic effects. So, Lynch Syndrome, um so HN PC, um which also increases the risk of colon cancer that is associated with a risk of ureteric and up TC um and exposure to certain chemicals. So, aristo cholic acid, for example, which is found in some Chinese herbal medications um also has been shown to increase the risk um but clearly age smoking, male gender and previous cancer in the bladder or the ureter are clearly the biggest risk factors. Another risk factor is um sort of unique to patients who have bladder cancer. And that's if you put a ureteric stent in um because you may see the tumor up um the ureter by having the stent in place because of the pushing effect that you need to do to put the stent in via the retrograde route. It also helps dilate up the ureter. So reflux is more likely and that can cause a metachronous tumor. That being said though stenting is sometimes inevitable and you need to do it because otherwise, for example, a patient may have ureteric obstruction and that's gonna destroy their kidney function because it can cause urethro er particularly in someone with poor renal function to start off with or a solitary kidney. Er, indeed, it may be needed in an emerg see like an infected obstructed system. Um and it may be needed after surgery. So, um ii, if you've resected the ureteric orifice during ATU R BT or if there's damage to the ureter, um or something like that, then putting a stent in can be a necessity to prevent acute and chronic complications like ureteric strictures, uh or clots within the ureter as well. So it's a, you really have to balance these risks and benefits um at the time. Um And, and often it is more safe to put a stent in. But often, actually, you have to think well, is this really needed needed? Can I leave this patient tubeless? If possible symptoms, I should probably jump to that last point. Upper. Your, your, er, upper tract TCC is commonly asymptomatic and is often found incidentally because we're all having more scans nowadays and we're all having more investigations, more having, um, er, treatments that people didn't have before. Um, and so commonly you might find you can get it from someone who's, er, in the urology department or someone that's completely incidental. You find someone with unilateral hydronephrosis seen on any one of those scans. Um, and those patients will need further investigation because you, you don't know the cause of the obstruction necessarily. Er, and if there isn't a cause, the, er, can consider a CT urogram, um, which is the gold standard investigation in most cases. But of course, hematuria can occur as with any cancer in the, er, uu urinary tract flank pain, uh because of an obstruction, um you know, much like a stone, but you don't get that same acute, severe colicky pain as you do in stones. And of course, you get your weight loss, uh fatigue, malaise, um lethargy, generally unwell loss of appetite kind of thing. So you're getting in metastatic cancer diagnosis as I've alluded to because of better imaging, our diagnostic rates have improved significantly. And, and that also means that patients are caught at earlier stages of the disease than they otherwise would have been as well. Ct urogram. Um So if you look to your er right, er that is an example of a CT urogram, er that is a delayed phase ct scan. Um by which the contrast has been injected into the veins, it's traveled back to the right side of the heart, gone into the pulmonary system, back to the left side of the heart, into the arteries, been filtered by the kidneys and then excreted um into the renal system. So it's gone through all of that. So that's why you need 45 minutes to an hour in order to actually see the contrast in the system where you need it to be. Um and it can be seen after that as well and after that period of time, um and it makes the ureters light up and the renal pelvis light up, er, and you can see filling defects. So you can see here where the arrow is, er, the contrast isn't filling where it should be. Um, and therefore you can, er, say there's clearly something blocking it off. Could it be a cancer that looks like a pretty nasty craggy mass? Um, that's very likely to be a cancer. Of course, there are other causes as well. Um, so a ct scan may not be able to distinguish between all causes of obstruction. Um, but, um, it is 92% sensitive and 95% specific. So it's very, very good indeed at diagnosing um upper tract TC, er, some II remember reading about this in medical school for some reason because it's quite old school. But previously I ride on an IV PLOM where you, you inject the contrast in the same way and take an X ray. Um but it's clearly just not as good as, as CT hematuria. Patients routinely have a CT urogram specifically to detect these tumors. Um So, rather than detecting bladder cancer, actually, the point of that CT is more to detect the upper tract er, tumors. Er, because if it's bladder cancer, we'll probably see it on a um flexible cystoscopy. It's incredibly unlikely that we'll find a tumor that wouldn't have been found on flexible cystoscopy. Um But obviously you can't do er, that investigation for um upper tract cancers. It's much better to do a CT scan. Um In those who can't have contrast, of course, you've got poor renal function for some reason, um, you can use an MRI scan although it's uh obviously harder to get and, and not necessarily better. Um And urinary cytology is an option uh but is of limited use. Um I'd say it's, you know, not particularly sensitive or um not particularly sensitive, sorry for um, upper tract TC or for bladder cancer. Um And so commonly comes back negative when, in fact, there is a case of cancer. So, um not usually the best thing uh to take for diagnosis, but some, sometimes people do take it uh and send it off and it can be useful. Um er but commonly misses a lot of things. So upper tract cancer is an indication for flexible cystoscopy as well because of uh patients are likely to have um bladder cancer as well. Uh And also some scan results may be unclear. Uh And so if there is any uncertainty about the presence or absence or or absence of upper tract cancer or if it's not clear if a lesion is benign, you maybe want to get a biopsy, um then some patients will go undergo a diagnostic ureteroscopy. Um Of course, this isn't routine. Not all patients suspected of getting of having your upper tract cancer will need a diagnostic ureteroscopy. Some patients will go straight to radical treatment or indeed other types of treatment for this condition without it. Um But for those who need more investigation before making that diagnosis, um direct visualization of the ureter and the cancer is useful through this method. Uh And so when also just so that, you know, whenever anyone says Urs, they mean ureteroscopy. Um so you can use piranha forceps, um sa er, when you safely can, er, sample the tissue for complete histological analysis and you can gain muscle from that for staging. Er, but of course, er, the uterus is a very, er, thin tubulous structure and it's er not difficult to er cause perforation. So it needs great care in doing that. Of course, patients with confirmed disease uh will need a staging ct thorax, abdomen, and pelvis to assess for metastases as well. So, a bit of surgery talking about ureteroscopy um generally performed under, under general anesthetic. Um but in theory, can er be done under local anesthetic and that's something that I've seen. But uh for diagnosis, um particularly in men uh require general anesthetic. Um The first step is to perform a cystoscopy. So, inserting a rigid cystoscope um into the bladder, finding the relevant ureteric orifice. So it's in, in the case in this cartoon, er, finding the right ureteric orifice, er with the cystoscope and then feeding a wire. So after a sensor wire, uh in these cases through the scope up into the ureteric orifice and then up to the kidney and you confirm where you are using um your X ray, take flesh and uh you can see if your wires coiling in around the right place can be pretty sure you're in the kidney. Many people will do a retrograde study whereby you inject contrast via ureteric catheter at that time as well. And then you can see the er calices um when you take an X ray as well that confirm that definitely confirms in the kidney and roughly where um your wire will be on future x rays taken during the procedure as well when doing cystoscopy. So it's important that you hold the penis up vertically um into the air because that straightens out the urethra prevents you from scraping the sides of the urethra with your cystoscope, er, and causing damage that can cause um potential ureteric strictures in the future as you move past the sphincter and enter this prostatic urethra. It's important to then rather than holding it vertically up in the air, drop your hands again to straighten out the urethra so that you can get your scope in without causing any damage to the epithelial layer. Then er you, once you've got your wire in, you've put your scope in, you use the seldinger technique, so you push your wire in as you're taking your scope out, um to ensure that your wire doesn't get displaced, take your scope out and then you feed your rigid ureteroscope, uh which is much longer and much thinner than a cystoscope. You can see an image of it. Um the, the metal one here, that's your semi rid ureteroscope. Um, and then you, you, er, place that through the urethra and into the bladder again, um, and then pass it underneath your wire ideally. So it's that you're into the ureter and that wire is acting as a safety wire. Er, it means that you're definitely going into the right place. Er, and you're not causing particular damage. Um, er, realistically there is a possibility you may need to, er, insert a second wire if the ureter is, is tight or if you find it difficult. Um, uh, but generally speaking, that's only done. Uh, if, if you're having having difficulty, once you're in the ureter, you advance proximately with your, er, semi rigid scope, keeping the lumen in the middle. Um, because again, you don't want to scrape those sides and doing it in the ureter can be really very, er, consequential for patients causing strictures. Um, you move approximately until you see that abnormality. Er, and you proceed with what you need to do. Sometimes you may be able to use a flexible ureteroscope. So there's a, again the image on the bottom, you can see how long it is to get into the ureter. Um, if you need to, er, er, if you need to do a camera deflexion as well and that can be fed over the wire, um, straight into the scope. Um, because, uh, and then that can be used to deflect, have a look at the renal Kass, see if you can see ureteric cancer within the renal pelvis. Um And, and if so, more areas to have a look, but generally speaking, it's, it's formed with a rigid scope because most of the cancer that you'll need to visualize um will not require that deflection that you get with the flexible scope urine samples. At this point when you're in the ureter and or the renal pelvis um is um usually much more useful because you're getting it directly from where the tumor is uh rather than having any cancer cells be diluted by the urine from the other kidney um er or being diluted altogether whilst it's flowing down. So, cytology is, is generally more sensitive when taken at this point rather than taken at er other points and you can take it directly from the scope. So again, it's quite, it's quite a small image. Uh but you can see um there are various er taps where you can put a syringe in such as here in the rigid scope, er or in this er connector here on the flexible scope and you can take a sample of the urine that you need. So, the great thing about ureteroscopy is that you can also uh be therapeutic with this. Um So you can feed laser wires through the scope to um do things like dust and fragment stones or ablate abnormal abnormal lesions such as uh cancers. But of course, when applying a laser to the ureter, of course, you can damage the natural lining and then you can cause perforations or such damage that causes scarring in strictures. So you have to be very careful when operating the laser and it's probably best to learn how to use the laser in um, easier cases. So, for example, I learned my first cases where I ever used the laser on my own, um, with a consultant assisting me or, or watching me was er, in the treatment of bladder stones because the bladder, of course, you have so much more space than you do in the ureter that allows you to gain more experience with operating a laser, get used to it in a much er, safer environment where you're much less, less likely to cause damage to uli doing so, er, may um, er, increase the risk of intravial occurrence, er, just because of the um seeding. Um, but also doing so, er, if you cause a perforation as well, um, beware of the fulcrum effect. Um So what if you, if, if you think all the way back to, to G CSE physics, um if you're operating something that's far away from you, you only need to have small movements um from, from your end of, of the object that you're moving in order to have big effects. Um And so because your scope is so long again, I'll show you again, it's so long you don't actually need to move your hands on the distal end of the scope very far in order to actually have a big effect once you're inside the patient, so very small subtle movements can have the desired effect. And it's a skill that just needs to be observed first and then affected as you go through your training, family screening. So it mentions that there are genetic associations with upper tract cancer. And so those with few risk factors for the disease, but who have the disease nevertheless, um should have genetic screening and all patients would have a thorough family history. And again, those with a family history of the condition should uh go for family uh screening. And this is through something called the Amsterdam two criteria which should be appearing on the screen. And this is from the European Association of Urology. So, er, rather than reading outer everything here, I'll just sign post that and you can see low risk factor patients. So young patients, those with a known um family history, of course, as well or with um clear first degree secondary relatives with the condition should have your DNA sequencing sequencing. Er, and of course, those who are more classic with all the risk factors, your older men who smoke um may with no family history, um may not be necessary to have the er er genetic screening, tumor grading. Uh. So most cancers of the upper tract will have high malignant potential, unfortunately. Um And so the classification includes papillary, er neoplasias of low potential, er, from, er, malignancy and spread and then there's low grade papillary, uh, upper tract cancers and then the high grade ones as well. Uh, but unfortunately the disease is very aggressive and that's why you have those 25% who are diagnosed with, uh, metastases at the time of diagnosis. Er, never mind those who aren't diagnosed with locally advanced disease without metastases but who still need significant, um, er, forms of treatment rather than, er, local, er, forms of treatment staging is fairly similar to bladder cancer, er, with slight differences related to the anatomy. Um, but effectively you can divide T one and below as non muscle invasive and then T two and above into muscle invasive and beyond. Um, and so T two being into muscle, three into the surrounding fat and four into the adjacent organs again, much like bladder cancer where T four is into your prostate. So your rectum's adjacent organs that are important to be aware of. Then the end staging, er, you have N one and N two, depending on how many lymph nodes are involved and then your m one for your distant metastases as well. It's often quite difficult to assess in um upper tract cancers. And so, rather than um just sort of having your TNM staging be the dominant way in which we divide tumors. Um, we have low risk and high risk. Um, and then we base treatment based on whether they're high low risk or high risk. And again, most patients will be high risk. It helps decide between the kidney sparing treatment and the radical nephroureterectomy, which is the main method of um treating for high risk patients as well as whether they receive chemotherapy, radiotherapy and other forms of non surgical management as well. Um So to have to, to be low and high risk, you have to have all of the features that are uh mentioned. So it needs to be a small tumor with one focus, nothing, high grade on the cytology or the biopsy. Um, and then, er, no uh evidence of invasion. So it's sort of t one and below. And so that's just going to be a, a minority of the, er, conditions, unfortunately. So I'm just gonna take this opportunity to see if you have any questions, um because I appreciate I haven't done that yet. So feel free to ask any questions if there's nothing I can crack on. But um there's a fair amount of information that we've spoken about. We've spoken about some of the surgical methods, investigative methods, diagnostic methods, um spoke about ureteroscopy, which you may or may not have experience with. So just let me know if there's anything you want me to answer, uh, it's quite difficult for me to see the chat whilst presenting. So that's why I've stopped showing the screen f if there's no questions, I'll just carry on. So low risk cases. Um should be offered kidney sparing surgery if possible. Um And they may involve endoscopic methods. So, we mentioned laser ablation uh but it also can involve er more um significant resections of the tumor plus anastomosis. So, a distal ureterectomy. Um so best for your low risk distal tumors um because they're the ones where you can manipulate the bladder in such a way that you can actually reimplant the ureter. Um Unfortunately, with the more proximal tumors, there may be low grade um with low malignant potential, but because there's high failure rates, um realistically, segmental resection is probably not going to be particularly useful because um it's not going to be er enough to actually get rid of the tumor long term. So that leaves the possibility of total ureterectomy plus uh using a section of the ilium um to connect the kidney and the remaining ureter um as well. Um You can form a stoma potentially and that can be the way of drainage, but um it's often not particularly uh nice for the patients, but then again, the cancer may be in the um better kidney. Uh So there could be one kidney that's well functioning that unfortunately, now has cancer in it. So you have to think about um what's the patient's split renal function um which can be investigated with a mag three renogram, um which is a type of nuclear medicine test. Um They may only have one kidney um and, and other considerations to see if you want to preserve those nephrons as much as possible. Um It may also be patient's choice as well. We have to consider what they want as well. Um There are percutaneous ablated methods for low risk renal pelvis tumors as well. So you can feed in er, er, er, devices that may be used to ablate or to destroy a tumor. Um However, those are not the gold standard methods of treatments. Um often better for our high risk anesthetic patients. Um who still warrant treatments, still desire treatments. Er, but for whom having major surgery is, is a big risk. Yes. And then there's nephroureterectomy, er, better known as neph U and it's the standard method for the treatment of upper tract cancer. Um because of the of high risk cancer, I should say I quite like this image because it shows why taking the kidney as well as the ureter is needed because when it's so high up, um just connecting uh replum in that kidney into either the bladder or into a stoma is just incredibly difficult um and often leads to oncological er complications. So, recurrence um progression, poor progression free survival and overall survival. Er, and just other complications, potentially things like urinoma if the urine leaks out of the remaining kidneys. So sometimes better to just take the whole thing out. Uh but also actually the, the cancer may exist further within the kidney with, within the more proximal urothelial tract as well. So it's actually inside of the kidney. And so it needs to go. Unfortunately, it can be performed with open laparoscopic and robotic assisted approaches. Er, and is characterized into two parts which, er, you may have guessed as the nephrectomy part and the ureterectomy part, um, such as, uh, kind of in the name of the procedure, advantages of open surgery. Um, there's no special equipment needed. Um, and so it can be performed in, in most centers, it's actually the fall back for minimally invasive cases. So, if you're struggling with a robot, for example, er, or laparoscopically, if the planes are very difficult, er, or if the patient's significantly overweight, um, and actually it's very difficult to perform the operation due to the um fat within the abdomen. Um, you can fall back onto this method. Operating times are also shorter for open surgery disadvantage. So the whole reason we don't do open surgery as much more in urology or in, in general surgery or other specialties is that more POSTOP to pain, higher risk of blood loss. Um, more uh common frequency, frequent need for blood transfusions, longer hospital stays, large scars which can then become infected or have uh leaking or psoas and therefore more deconditioning, then hospital require infections, et cetera, et cetera, et cetera. So, those are the er, disadvantages for and those are pretty generic for all open surgeries to be fair. The approach to open radical neph view can be through the flank or anteriorly. So you can position the patient in the proper way. Um And then the approach can be via the retroperitoneal transperitoneal or thoracoabdominal roots as well. So, retroperitoneal effectively being going from behind transperitoneal going through and the anterior structures um to the kidney um or, or because the kidneys high up um a thoracoabdominal roots as well. Er And this is an image as well. So you can see here this is er positioning the patient so you can er go via the retroperitoneal route. Er, and here's a scar you might see in someone who's gone transabdominally as well. The laparoscopic and robotic cases are generally performed with flank incisions. Um the renal artery er, or arteries as the case may be, er, need to be clipped before the renal veins. Um And I'm gonna ask if anyone knows why that might be, why might we need to get the arteries before the veins, which is the same in a uh nephrectomy as well will be much more simple than you might be thinking the reason why. Yeah. Yeah, exactly. So, in effect, if you cut off the patient's um renal veins, whilst they're still, the kidneys are still uh being filled up with blood from the arteries, um then the kidneys will continue to have a blood supply without anything draining it. And so the kidneys will fill with blood uh and then you'll have a high risk of bleeding. Um The unfortunate side of that is that the renal veins, uh so renal arteries are posterior to the renal veins and they're, they're deep to the renal veins. Um And so they're more difficult to access um uh initially and so, uh that just makes the operation more tricky than it, it would otherwise have been. Um So, you know, it's still necessary though, nevertheless. Um And so that's why we need to find and clip the arteries before we do the veins. And that's why it's really important to understand the pathological. Um and the appearance of arteries and veins that you can see. Um, not just because one, you know, one set is red, one set is blue, but actually what they look like features your tunica. Um uh you know, the fact that the, the arteries are more sort of circular because of the muscle that they have and the veins are more distensible, er, because that, and also the fact that the arteries are deeper to the veins because that will allow you to identify what's artery and what's vein. Um and therefore allow you to clip uh the correct things uh before you make any mistakes. So, a radical nephro nephroureterectomy involves much like radical nephrectomy, uh removing the kidney, the paranephric fat, paranephric fat and the duross fascia. And your key considerations uh to avoid spillage of urine because you can cause a urinoma collections and they can get infected ensuring that the ureter is completely removed, including the cuff of the bladder as well. While the, where the ureter implants, uh and of course, if someone's got a cancer that's causing obstruction within the ureter, they can get hydronephrosis and the hydronephrotic kidneys because they have more pressure within them. Um And the walls potentially are thinner, uh they can be easier to rupture. So just consider that when you're uh looking at doing this operation, not uh not removing the bladder cuff has been associated with poorer cancer specific um and overall survival because patients are more likely to get recurrence. Um And this section of the operation can be done also by open and minimally invasive approaches. Bladder cuff excision also requires a cystoscopy er and er er incision around the ureter ce from the inside, er as well as er removal from the outside. Um and it can be done sort of within or outside of your bladder, additional management options. Um We've sort of touched on these um and I'm, I'm just gonna be brief on them. Uh But because cancer is a systemic complicated condition, er you can facilitate your outcomes with neoadjuvant and or adjuvant chemotherapy. So, neoadjuvant being before you do your operation, adjuvant being after the operation, um dissecting lymph nodes um separately to the actual removal of the kidney and the ureter to make sure any of those uh metastatic nodes are removed as well because otherwise the cancer is still going to be inside and still going to spread cancer within the bladder. So, um if you remember back to the bladder cancer session, uh we, we often inject mitoMYcin to prevent recurrence. And it's similar here. Uh There are forms of immunotherapy and radiotherapy that can be delivered as well. The follow up you receive depends again on the risk category category that you fall into. Um So after radical nephroureterectomy, if you're low risk, you'll get a cystoscopy at three months. And if negative, um you'll have a nine month cystoscopy and then yearly for five years. Um but obviously, if you're positive, you'll then go on to treatment. Uh And so this is, this is bladder cancer. So then onto tur BT um or another appropriate option based on the patient's fitness and desires and, and, and what they've been through already, um high risk cancers uh will require a cystoscopy in your in cytology at three months, which is similar to the low risk. Uh But if they're negative rather than doing it at nine months, you do it every three months for two years, then every six months for five years and then yearly thereafter that you'll also receive a ct urogram and thorax, six monthly for two years and then yearly just for surveillance, er, for any metastases um or for any spread, er, locally or recurrence within the operative bed that you might have missed um, er, during the nephew. So that brings us to the end of the session. Um Thank you very much for listening. Um, again, like I said, it's, it's something that's not often covered, um, but hopefully, uh, things like ureteroscopy, um and nephroureterectomy, distal ureterectomy, bit more clear, um, understanding how this condition can present and the investigations required, er, appreciate the sessions a bit shorter than the other ones that we've done. But that's because it's, it's not as much to cover necessarily, um, and happy to take any questions. Um, and please do leave a feedback form at the end as well. Alright, thanks guys. I believe the slide deck is already uploaded if you want to have a look again, uh, as it is for, uh, I believe for all of the sessions so far, so have a look at that. Um, yeah, just let us know what you think. Um, if there are no questions, we'll, I'll leave you be uh, go and enjoy your Wednesday evening and, um, you can let me know if there's anything else you particularly want covering as well. Um, we'll do our best to try and cover what you guys think you need as well fav I'm going to head off guys assuming there's no questions. Um I hope you have a very good evening.