Ureteroscopic approach:
- Allows biopsies (basket, biopsy forceps, backloaded biopsy)
- Laser ablation of tumours (Ho:YAG) or bugbee cautery
- I prefer low setting of 0.5 J and 5 Hz, which allows for coagulation also
- For low grade lesions – ureteroscopic management is akin to management of low grade bladder cancer – there is a reasonably high recurrence rate, but low progression rates (?15 – 20 %) and therefore good survival outcomes
- High grade lesions are highly likely to recur and endoscopic management should be considered palliative
Risks of ureteroscopic management are recurrence, stricture, clot colic or transient obstruction, and the need for frequent GAs.
Percutaneous approach:
- Used in select situations
- Larger, low grade tumours of renal pelvis
- Difficult to access lower calyx tumours
- No retrograde access i.e. ileal conduit
- May allow access for instillation of BCG or MMC
Risks of percutaneous access are the normal risks (bleeding, viscera injury), and a higher risk of tumour seeding due to defined breach of the urothelium.