1. Case 3 75 Yr male. pT1 TCC upper ureter. Smoker CKD stage 2 Diabetic Monday morning. Patient admitted for lap nephroureterectomy. Discuss procedure and consent.

2. Consent Lap. Nephroureterectomy Discuss: – operative procedure (including discussion of management of distal ureter). – peri-operative management. – complications – follow up (including cystoscopy surveillance) – alternatives to treatment. Complications Common (greater than 1 in 10)  Shoulder tip pain.  Abdominal bloating.  Recurrence of disease elsewhere in the urinary tract. Occasional (between 1 in 10 and 1 in 50)  Bleeding, infection, pain or hernia of the incision needing further surgery.  Need for additional treatment for cancer after surgery. Rare (less than 1 in 50)  Recognised (or unrecognised) entry into the pleural cavity and possible chest drain insertion.  Recognised (or unrecognised) injury to organs/blood vessels needing conversion to open surgery (or deferred open surgery).  Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death).  Renal failure (temporary or permanent) requiring dialysis.  The pathology in the kidney may subsequently be shown not to be cancer.  Persistent urine leakage from the bladder needing prolonged catheterisation or further surgery. Hospital-acquired infection  Colonisation with MRSA (0.9% - 1 in 110).  MRSA bloodstream infection (0.02% - 1 in 5000).  Clostridium difficile bowel infection (0.01% - 1 in 10,000).

3. 67 Yr female. Smoker. CKD stage 3a. Previous recurrent multifocal G2pTa TCC bladder. Course of mitomycin 3 years ago (no recurrence since). Visible haematuria 6 weeks ago. What would you do? Case 4 - introduction

4. Case 4 – initial evaluation History - 2 episodes of visible haematuria 6 weeks ago (none since). Examination - normal MSU – no evidence of infection. Flexible cystoscopy – normal. CTU – poor contrast filling of distal ureters, but no obvious abnormality. What next?

5. Case 4 – first URS Bilateral ureteroscopy. Small papillary tumour distal 1/3 left ureter. Removed with basket and LASER to base of tumour. No other abnormalities. Low grade TCC Path report – G2pTa What next?

6. Case 4 – follow up Follow up URS in 3 months. Normal bladder. No evidence of upper tract tumour. Lost to follow up, living in Costa Brava for 3 years. Represents again with visible haematuria. What do you do?

7. Case 4 – re-evaluation History – intermittent haematuria for 12 months. Examination normal. Flexi cystoscopy: – 5 small papillary tumours in bladder. – ? tumour protruding from left U.O. What next?

8. CT 2 days prior to ureteroscopy. What does it show? Bilateral URS – large tumour in right renal pelvis – biopsy taken. Multiple small papillary tumours left distal 4 cm ureter – biopsy and LASER. High grade TCC Path report - right renal pelvis G3pT1 - left lower ureter G2pTa - bladder G2 pTa

9. Case 4 – definitive managment Patient returns to clinic to discuss results and treatment options: Summary of case – 67 Yrs, female, CKD stage 3a and smoker. – CT thorax requested at time of URS reported as clear. – CTU – renal pelvis TCC right – no other disease visible. – Recurrent G2 pTa bladder – Recurrent G2 pTa left distal ureter – New large G3 pT1 right renal pelvis