Schematic model.

Operative animation, Ureteroscopy for upper-tract tumour

Kidney-sparing ureteroscopic biopsy and laser ablation of an upper-tract urothelial tumour

Indications

  • A low-risk upper-tract urothelial tumour: the EAU guideline offers kidney-sparing management first (strong).
  • Diagnosis and risk stratification when imaging and voided cytology are not enough.
  • A solitary or poorly functioning opposite kidney, or a patient unfit for nephroureterectomy, after discussion.

Alternatives

  • Radical nephroureterectomy, the standard for high-risk disease.
  • Distal ureterectomy for a low-risk tumour of the distal ureter, which the guideline says to discuss alongside endoscopy.
  • Percutaneous antegrade resection or ablation for a large or inaccessible renal pelvic or calyceal lesion.

Risks

  • Bleeding, infection and pain or urinary symptoms from the stent.
  • Ureteric perforation, avulsion or later stricture.
  • Residual, recurrent or under-staged tumour, and recurrence in the bladder.
  • Failure to reach, biopsy or remove the tumour.

Endoscopic treatment of a small papillary urothelial tumour of the renal pelvis, with the kidney left in place.

Cystoscopy comes first, then selective urine cytology through a ureteric catheter, a retrograde study, a safety wire, a semirigid look at the lower ureter and the flexible ureteroscope to the tumour.

Every calyx is inspected, the tumour is biopsied before anything else touches it, then ablated with the holmium laser down to a white base, and a stent is left. The lesson is selection and sequence: a sample good enough to grade, a wall that is thin, and a second look booked.

Advanced tier FRCS urological oncology, upper tract urothelial carcinoma, endourology Interactive 3D
Schematic scene preview: Ureteroscopy for upper-tract tumour
Preparing the 3D anatomy…

UrOops3D · UroRef · © Nity G

How to use this module. Play the nine steps, or use Back and Next. The 3D view is the kidney and its ureter; the panel is the screen or the scope view. Watch the biopsy come before the laser, the fronds go, and the base whiten. The triggers show a perforation, bleeding and an under-staged tumour.

Click me next Section 2 of 8 Anatomy The structures this operation works between, and the one it must not cross.

The structures in the scene

Ureteroscopy for upper-tract tumour: how the structures relateA papillary tumour in the renal pelvis, seen from the flexible ureteroscope. Tumour base on the pelvic wall: ablated last: carries them; biopsied first, then ablated Papillary fronds. Tumour base on the pelvic wall: ablated last: deep to the wall under it; a deep burn reaches Renal sinus vessels (danger). Tumour base on the pelvic wall: ablated last: reached through it; never forced Ureter: thin wall (danger). Tumour base on the pelvic wall: ablated last: every one inspected before it is touched Upper, middle and lower calyces. Tumour base on the pelvic wall: ablated last: faces it, opposite the scope as it arrives Pelviureteric junction. Tumour base on the pelvic wall: ablated last: high pressure drives irrigant into them Renal veins: pyelovenous backflow (danger).Tumour base on thepelvic wall: ablatedlastPapillary fronds!Renal sinus vessels!Ureter: thin wallUpper, middle andlower calycesPelviuretericjunction!Renal veins:pyelovenous backflowcarries them;biopsied first,then ablateddeep to the wallunder it; a deepburn reachesreached through it;never forcedevery one inspectedbefore it istouchedfaces it, oppositethe scope as itarriveshigh pressuredrives irrigantinto themTargetDangerLandmark
A papillary tumour in the renal pelvis, seen from the flexible ureteroscope. Schematic, not to scale; relationships only.
  • The left kidney is seen from the front, the ureter running down to a schematic bladder.
  • The tumour stands on the wall of the pelvis opposite the pelviureteric junction, facing the scope as it arrives.
  • The close views look from the medial side through the thinned pelvis.
  • The round panel is the scope view.
  • ›Renal pelvis - the tumour sits on its wall opposite the pelviureteric junction, here in the left kidney.
  • ›Papillary tumour - fronds on a stalk or a base; the fronds are biopsied and ablated, then the base.
  • ›Tumour base - where the tumour meets the urothelium; it is treated last and whitens as it coagulates.
  • ›Calyces - upper, middle and lower; every one is inspected for a second tumour.
  • ›Ureter - thin-walled along its whole length; the scopes go up it under vision and screening.
  • ›Pelviureteric junction - where the ureter opens into the pelvis; the working wire comes out just below it.
  • ›Renal sinus vessels - outside the wall of the pelvis and the infundibula; out of reach of a shallow burn.
  • ›Ureteric orifice - the left orifice at the corner of the trigone, where every instrument enters.
  • ›Safety wire - the first wire up, kept for the whole case: the rail for the stent and the way back.
Click me next Section 3 of 8 Steps The operation in order, with the landmark that guards each move.

Operative steps

  1. Cystoscopy, cytology, retrograde study In lithotomy, after intravenous antibiotics, the cystoscope is passed under vision and the bladder inspected for tumour. An open-ended catheter is passed up the left ureter; urine is collected for cytology before any contrast, then a retrograde study outlines the system and shows the filling defect.
    where it bites: contrast first spoils the cytology sample; the urine is taken before it.
  2. Safety wire A guidewire is passed through the catheter and advanced to the kidney under fluoroscopy until its curl is seen in the collecting system. The catheter and cystoscope are withdrawn. This wire stays in for the whole case as the safety wire.
    where it bites: nothing follows a wire whose tip has not been seen in the kidney.
  3. Semirigid look, working wire The semirigid ureteroscope is passed up the lower ureter beside the safety wire and the ureter inspected under vision. A second, working wire is passed through it to the renal pelvis, and the scope comes out over it. A dual-lumen catheter is the other way to place the second wire.
    where it bites: the ureteric wall is thin; the scope is advanced on a clear lumen and never pushed against resistance.
  4. Flexible ureteroscope The flexible ureteroscope is advanced over the working wire into the bladder and up the ureter under fluoroscopy. In the upper ureter the working wire is removed and the scope advanced under direct vision. A papillary tumour is seen on the wall of the renal pelvis.
    where it bites: a scope that stops is not forced: perforation and avulsion are listed complications.
  5. Inspect every calyx A thorough ureteropyelocalycoscopy: the upper, middle and lower calyces and the whole pelvis are inspected before the tumour is touched, with irrigation kept low and the view clear. Here the tumour is single: unifocal.
    where it bites: irrigation pressure in a closed system drives fluid into the veins; keep it low and let it drain.
  6. Biopsy before ablation Biopsy forceps are passed through the working channel to the tumour and biopsies are taken under direct vision, two bites here, and sent to pathology. A basket or nitinol extractor can take the sample instead. Only then is energy used.
    where it bites: a sample taken after ablation is burnt and cannot be graded.
  7. Laser ablation to the base The holmium laser fibre is advanced out of the scope and seen on the tumour before each activation. The fronds are ablated down to their base, and the base is then treated until it whitens. Power is kept low, so that heat is not carried into the wall.
    where it bites: the renal sinus vessels lie beyond the wall of the pelvis; a deep burn reaches them.
  8. Check and withdraw The pelvis and calyces are inspected for residual tumour, bleeding and trauma, and any bleeding point is touched with the laser. The scope is withdrawn slowly under direct vision, confirming an intact ureter without undue bleeding.
    where it bites: tumour left behind is the commonest failure of this treatment; look again before leaving.
  9. Stent and second look Over the safety wire a double-J stent is advanced so that its ends lie in the renal pelvis and the bladder, and its position is confirmed on fluoroscopy. The wire and cystoscope are withdrawn under vision. A second-look ureteroscopy is planned within eight weeks.
    where it bites: a stent drains the kidney but hides nothing: follow-up is the second look, not the stent.
Click me next Section 4 of 8 Danger zones Where this operation bites, and why it bites there.
Critical relationship

Danger zones

The spatial relationships the animation is built to make automatic. Before you read each one, ask yourself: at this point in the operation, what is about to go wrong, and what is my first move? The save for each sits in the Complications tab.

  • RiskThe thin ureteric wall - every scope passes up it; perforation, avulsion and later stricture follow force.
  • RiskRenal sinus vessels - beyond the pelvic wall under the tumour base; a deep or high-power burn and a deep biopsy reach toward them.
  • RiskCollecting-system pressure and pyelovenous backflow - irrigation in a closed system drives fluid and bacteria into the veins; pressure kept low.
  • RiskThe biopsy itself - a sample too small or too burnt to grade under-stages the tumour, and the whole plan rests on it.
  • RiskPleura and adjacent organs - a risk of the percutaneous variant, through a tract above the twelfth rib; not of this retrograde route.
Practise it Take me into the scene Opens the animation at a danger moment and asks you to predict the mechanism and your first move before it reveals.
Click me next Section 5 of 8 Complications The save for each one: the first move, the escalation trigger, the op-note line.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

Ureteric perforation with extravasation

  • a scope or wire forced against resistance passes through the thin ureteric wall, and contrast or irrigant is seen outside it.
  • A listed complication of the operation, with avulsion and intussusception.
The save
  1. Stop advancing. Keep the safety wire where it is: it is the way across the hole. first move
  2. Screen with a little contrast to see where the leak is and how large.
  3. Abandon the treatment for today and place a double-J stent over the safety wire.
  4. A wire that has been lost across the hole, a large leak or a suspected avulsion is for senior help now; nephrostomy drainage may be needed. escalation trigger
  5. Bring the patient back for treatment after the ureter has healed, and watch for stricture.
  6. Op note: where the perforation was, how it was seen, the stent placed and the plan to return. document

Bleeding that takes the view

  • a biopsy or the laser opens a bleeding point at the base and the blood clouds the pelvis.
  • A listed complication; the chapter names the holmium laser for bleeding as well as for ablation.
The save
  1. Stop working. Irrigate gently and let the field settle. first move
  2. Find the point and coagulate it with the laser fibre, low power, short bursts.
  3. Do not raise the irrigation pressure to clear the view: that drives fluid into the veins.
  4. A view that will not clear: stent and come back. Bleeding that continues after the stent is for senior review. escalation trigger
  5. Op note: the bleeding point, how it was controlled, and whether the tumour was fully treated. document

Under-staged tumour

  • the biopsy was small and could not be graded, and a flat sessile part of the tumour at the edge of the base was missed.
  • Small ureteroscopic samples often lack lamina propria, so stage and grade can be under-called.
The save
  1. Leave the stent and do not call the tumour low risk on a sample too small to grade. first move
  2. Repeat the look with an adequate biopsy, by forceps or basket, before any further ablation.
  3. Review the case at the multidisciplinary meeting with the pathology, the cytology and the imaging together.
  4. A high-grade result, an invasive appearance or a sessile tumour moves the plan to nephroureterectomy, to be discussed with the patient. escalation trigger
  5. Op note: the number of samples, their adequacy, and anything left untreated. document
Click me next Section 6 of 8 Troubleshooting When the case turns: the problem, then the next move.

Intra-operative troubleshooting

When the case turns: the problem, then the next move.

  • ActionThe scope will not pass the ureterovesical junction - it is not forced. The chapter allows dilation over a wire with a balloon or a tapered dilator; the alternative is a stent and a return when the ureter has dilated.
  • ActionThe tumour is in the lower ureter - the chapter allows a rigid ureteroscope and a single guidewire for a lower ureteric tumour.
  • ActionMany passes of the scope are expected - for definitive treatment the chapter allows an access sheath over a working wire, the smallest calibre that passes, never forced, sited in the mid to proximal ureter.
  • ActionThe view is poor from bleeding or debris - stop, irrigate gently and let it settle; do not raise the pressure. If it does not clear, stent and return.
  • ActionThe tumour is in a lower-pole calyx the tip cannot reach - release the flexion and come back to the pelvis; an antegrade percutaneous approach is the guideline route for a lesion that cannot be reached from below.
  • ActionThe biopsy comes back as not gradable - it is repeated. The plan for a kidney-sparing pathway rests on the grade.
Click me next Section 7 of 8 FRCS viva Say it out loud, then mark yourself against the model answer.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

QA 68-year-old has a filling defect in the left renal pelvis on CT urography. Which patients do you treat with the kidney left in place?reveal answer
  • Those with low-risk disease.
  • I would complete the work-up with cystoscopy, voided cytology and CT urography, and diagnostic ureteroscopy where imaging and cytology are not enough.
  • The EAU guideline stratifies the tumour by grade, appearance on imaging, cytology, size and focality.
  • A unifocal tumour under 2 centimetres, low grade on cytology and on ureteroscopic biopsy, with no invasive features on CT, is low risk;
  • the guideline recommends kidney-sparing management as the first option for low-risk tumours, a strong recommendation.
  • It calls grade the most important surrogate for stage, and cites a multicentre series of 932 patients in which 2 centimetres was the best threshold for invasive disease.
  • High-grade cytology or biopsy, or invasion on imaging, points to nephroureterectomy.
  • Some patients with higher-risk disease are treated endoscopically because they have a solitary kidney or poor renal function, and I would tell them that this is an imperative choice with a higher risk of progression.
  • Whatever the route, I would discuss the patient at the multidisciplinary meeting and make the decision with them.
Strong pass

Say all three

  • Naming the low-risk criteria together
  • All of them required
  • Saying that grade from an adequate biopsy carries the decision
Examiner note
Naming the low-risk criteria together, all of them required, and saying that grade from an adequate biopsy carries the decision.
QTalk me through the ureteroscopy.reveal answer
  • After antibiotics and in lithotomy, I would begin with cystoscopy to exclude bladder tumour.
  • I would pass an open-ended catheter up the ureter and collect urine for selective cytology before any contrast, because the guideline prefers barbotage cytology before contrast, and then do a retrograde study.
  • I would place a safety wire to the kidney under screening and a second, working wire, then pass the flexible ureteroscope over the working wire to the upper ureter, remove the wire and go on under direct vision.
  • I would inspect every calyx and the whole pelvis before touching the tumour, with irrigation kept low.
  • I would biopsy first, with forceps or a basket, and only then ablate with the holmium laser down to the base, at low power.
  • Then I would look for residual tumour, bleeding and trauma, withdraw slowly under vision inspecting the ureter, and leave a stent over the safety wire.
  • The guideline adds that complete destruction is necessary and that excessive power causes thermal injury.
Strong pass

Say all three

  • Cytology before contrast
  • The full map before the tumour is touched
  • The biopsy before any energy
Examiner note
Cytology before contrast, the full map before the tumour is touched, and the biopsy before any energy.
QHow reliable is the biopsy you have just taken?reveal answer
  • It is good for grade and poor for stage.
  • The guideline states that ureteroscopic biopsies determine grade in over 90 per cent of cases, but that small samples frequently lack lamina propria, so stage from them is unreliable.
  • Subiela and colleagues pooled 23 studies and 3,547 patients: grade matched the final specimen in 66 per cent of low-grade and 97 per cent of high-grade biopsies, and the undergrading and understaging rates were 32 and 46 per cent.
  • So a high-grade biopsy can be believed, and a low-grade one is a probability.
  • That is why I take an adequate sample before ablation, read it together with cytology and imaging, and plan a second look.
  • A sample too small to grade is repeated, not treated as low risk.
Strong pass

Say all three

  • Knowing that undergrading
  • Understaging are common
  • Acting on it with an adequate sample and a second look
Examiner note
Knowing that undergrading and understaging are common, and acting on it with an adequate sample and a second look.
QWhat follow-up do you arrange, and is there a role for instillation?reveal answer
  • The guideline recommends a second-look ureteroscopy within eight weeks of the first endoscopic treatment, a weak recommendation, to make sure the tumour has been completely treated, because local recurrence is common: it quotes ipsilateral recurrence in about one in two patients within two years.
  • After a negative second look, for low-risk disease it suggests cystoscopy at three and six months and then yearly for five years, and CT urography on the same schedule, with or without ureteroscopy.
  • On instillation, the guideline describes antegrade BCG or mitomycin C after complete tumour eradication, studied mainly for carcinoma in situ, and an early single instillation of mitomycin C into the upper tract that may reduce local recurrence in low-grade disease.
  • It also notes that recurrence rates after instillation are comparable to those in untreated patients, which questions their efficacy.
  • I would offer it only within a protocol, after discussion at the multidisciplinary meeting.
Strong pass

Say both

  • The second look within eight weeks
  • An honest account of how weak the evidence for upper-tract instillation is
Examiner note
The second look within eight weeks, and an honest account of how weak the evidence for upper-tract instillation is.
QHow does this compare with nephroureterectomy?reveal answer
  • For low-risk disease, survival appears similar and the kidney is kept, at the cost of more local recurrence and more procedures.
  • The guideline says so, and the systematic review behind it, by Seisen and colleagues for the EAU panel, found 22 retrospective comparative studies.
  • Ureteroscopic management was compared with nephroureterectomy in five studies, 162 against 367 patients.
  • Cancer-specific survival was similar only for low-grade, noninvasive tumours, with a higher risk of local recurrence after endoscopic treatment, and the authors warned of a selection bias in favour of kidney-sparing surgery.
  • So I would tell the patient that the oncological case rests on careful selection and on accepting an intensive surveillance programme of repeated ureteroscopy and imaging, and that a high-grade result at any point turns the plan toward nephroureterectomy.
  • The guideline also asks that endoscopic treatment and distal ureterectomy are both discussed for a low-risk tumour of the distal ureter.
Strong pass

Say all three

  • Similar survival only for well-selected low-grade disease
  • With more local recurrence
  • The selection bias named
Examiner note
Similar survival only for well-selected low-grade disease, with more local recurrence, and the selection bias named.
Click me next Section 8 of 8 Evidence The guidance each of these answers is built on.

Evidence and guidance

Operative Dictations in Urologic Surgery
Armenakas NA, Fracchia JA, Golan R. Ureteroscopy for tumors. Chapter 80. Wiley, 2019
The indication, the seven essential steps, the template dictation followed step by step, the variations and the complication list (bleeding, infection, failure to access, biopsy or remove the tumour, pain and urinary symptoms, urethral, bladder or renal injury, ureteric perforation, avulsion or intussusception, instrument breakage). The chapter takes cytology through the open-ended catheter before the retrograde study, names forceps, a nitinol extractor or a basket for the biopsy and the holmium laser for ablation and bleeding; its dictation fulgurates with a monopolar electrode. Sizes, pressures and the energy setting are kept off the page. The semirigid look that places the working wire follows the owner’s RIRS decision and the chapter’s variation for the lower ureter. Management lines for the complications and the danger lines are general practice.
Open guideline
EAU Guidelines
Upper Urinary Tract Urothelial Carcinoma, 2026: chapters 5 (diagnosis), 6 (risk stratification), 7 (disease management) and 8 (follow-up), read 18 October 2026
Kidney-sparing management as the primary option for low-risk tumours (strong); endoscopy and distal ureterectomy both discussed for a low-risk distal ureteric tumour (strong); second-look ureteroscopy within eight weeks (weak); ablation preferably with lasers, excessive power avoided, complete destruction necessary; recurrence in one in two within two years; barbotage cytology before contrast; grade from biopsy in over 90 per cent, stage unreliable; 2 cm as the size threshold; upper-tract BCG or mitomycin C and their doubtful efficacy; follow-up by cystoscopy and CT urography at three and six months, then yearly. The risk figure is an image and was not read; its footnote that every low-risk factor must be present was. The factors in the first viva answer come from the chapter text on each factor.
Open guideline
European Urology
Masson-Lecomte A, Birtle A, Pradere B, et al. European Association of Urology guidelines on upper urinary tract urothelial carcinoma: summary of the 2025 update. Eur Urol 2025;87:697-716
Abstract read 18 October 2026. A complete revision of risk stratification and ureteroscopy, and two new recommendations on kidney-sparing management of localised low-risk disease.
Open guideline
European Urology
Seisen T, Peyronnet B, Dominguez-Escrig JL, et al. Oncologic outcomes of kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma: a systematic review by the EAU guidelines panel. Eur Urol 2016;70:1052-1068
Abstract read 18 October 2026. Twenty-two retrospective comparative studies; ureteroscopy against nephroureterectomy in five (162 against 367 patients). Similar cancer-specific survival only for low-grade, noninvasive tumours, with more local recurrence after endoscopic treatment; a selection bias favouring kidney-sparing surgery. Used in the fifth viva answer.
Open guideline
European Journal of Surgical Oncology
Subiela JD, Territo A, Mercadé A, et al. Diagnostic accuracy of ureteroscopic biopsy in predicting stage and grade at final pathology in upper tract urothelial carcinoma: systematic review and meta-analysis. Eur J Surg Oncol 2020;46:1989-1997
Abstract read 18 October 2026. Twenty-three studies, 3,547 patients. Grade matched in 66 per cent of low-grade and 97 per cent of high-grade biopsies; undergrading 32 per cent and understaging 46 per cent. Used in the third viva answer and the under-staged complication.
Open guideline

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topics Urological oncology and Endourology. Not a workplace-based assessment and not evidence of competence.

Two minutes

Close the lap: recall it before you leave.

Say it aloud, then reveal. Reading is not remembering.

  1. 01 The relationship Say the critical spatial relationship out loud, then reveal. reveal
    Memory frame

    The left kidney is seen from the front, the ureter running down to a schematic bladder.

    Why?
    The tumour stands on the wall of the pelvis opposite the pelviureteric junction, facing the scope as it arrives. The close views look from the medial side through the thinned pelvis. The round panel is the scope view.
  2. 02 The first move Ureteric perforation with extravasation. Your first move? reveal
    First move

    Stop advancing.

    More detail
    Keep the safety wire where it is: it is the way across the hole.
  3. 03 The escalation trigger Ureteric perforation with extravasation. What makes you call for help? reveal
    Escalate when

    A wire that has been lost across the hole, a large leak or a suspected avulsion is for senior help now; nephrostomy drainage may be needed.

  4. 04 The discriminator What turns a pass into a strong pass? reveal
    Strong pass

    Say all three

    • Naming the low-risk criteria together
    • All of them required
    • Saying that grade from an adequate biopsy carries the decision
    Examiner note
    Naming the low-risk criteria together, all of them required, and saying that grade from an adequate biopsy carries the decision.
  5. 05 The pitfall Where does this operation bite first? reveal
    Pitfall

    The thin ureteric wall

    Why?
    every scope passes up it; perforation, avulsion and later stricture follow force.

Revision practice with self-marked answers, not an assessment of clinical competence. Kept in this browser only; it does not sync between devices.