BackTable Urology

Dr. Aditya Bagrodia talks with Dr. Lee Zhao, director of the Male Reconstructive Surgery program at NYU Urology, about indications, surgical techniques, and post-operative management for patients requiring upper tract ureteral reconstruction.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/OoURn7---CHECK OUT OUR SPONSORSAthletic Greenshttps://www.athleticgreens.com/backtableuroLaurel Road Physician Bankinghttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia talks with Dr. Lee Zhao, director of the Male Reconstructive Surgery program at NYU Urology, about indications, surgical techniques, and post-operative management for patients requiring upper tract ureteral reconstruction.First, Dr. Zhao outlines his indications for upper tract reconstruction in patients with ureteral strictures. Most of his patients come from subspecialized urologists, while the other half come from self-referral. Before surgery, Dr. Zhao assesses three areas: kidney function via a renal scan, the anatomy and location of the stricture via antegrade and retrograde pyelograms, and assessment of bladder function via a cystogram. Additionally, he takes pre-existing stents out to allow the ureter to rest.If a patient has a stricture less than 2 cm long, endoscopic management may be possible. However, if the stricture is longer than 2 cm, Dr. Zhao utilizes robotic surgery. Although he and Dr. Bagrodia discuss both single port and multiport approaches, he prefers the single port approach. He usually tries to avoid interfering with adhesions from previous surgeries and performs a concurrent ureteroscopy while gaining access. Only in cases involving obliterative strictures does he consider nephropexy.For simple cases involving virginal abdomens, Dr. Zhao usually performs a primary ureteroureterostomy (UU). For longer strictures, he will choose to place a graft. He uses two types of grafts depending on which ureter is affected. For left sided strictures, he will perform a buccal mucosa ureteroplasty. For right sided strictures, he will use an appendiceal graft. Both grafts are able to fix strictures up to 10 cm in length. For longer strictures, he will create an ileal ureter, in which he makes an anastomosis between the ureter and the bowel. A trans UU is unusual to perform because complications are possible that will cause both tracts to fail. Dr. Zhao treats mid and proximal ureteral strictures the same but adds that Boari flaps may also be an option in mid-ureteral strictures. For distal ureteral strictures, boari flaps, psoas hitch, and other procedures can be considered instead. For distal ureteral strictures, Dr. Zhao prefers to do a non-transecting reimplant, which consists of making a longitudinal incision of ureter at stricture and dropping the bladder down to the level of stricture. This technique is best to preserve inferior blood vessels, which can be useful in patients who have fragile vascular supply from radiation therapy.Finally, the doctors discuss post-operative management of reconstruction patients. Dr. Zhao does not routinely place a stent in all his patients and instead saves them for his buccal mucosal graft patients. Similarly, because he assesses the integrity of his anastomoses in the OR through retrograde filling or with the ureteroscope, he rarely places a drain after surgery. Finally, he prescribes post-operative antibiotics conservatively depending on the surgical technique chosen.

Dr. David Canes and host Dr. Aditya Bagrodia talk about attitudes, practices, and anecdotes to help resident and attending surgeons avoid complications.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/3aXPp4---CHECK OUT OUR SPONSORAthletic Greenshttps://www.athleticgreens.com/backtableuro---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. David Canes from Lahey Medical Center about attitudes, practices, and anecdotes to help resident and attending surgeons to avoid surgical complications.First, the doctors discuss pre-operative rituals. Both doctors agree that reviewing relevant films and picturing the operation step-by-step is very important. Additionally, they emphasize the importance of putting the patient at ease before the surgery. Dr. Canes leaves sticky notes on patient charts that remind him of small personal details about the patient. He usually mentions these details to the patient the morning before their surgery in order to put them at ease. Dr. Bagrodia prefers to call his patients and reassure them the night before the operation. In the OR, Dr. Canes always takes his time-out meetings seriously and makes sure that everyone is able to introduce themselves. Dr. Bagrodia usually takes a moment of silence to personally reflect on the patient before starting the operation.Next, they discuss the qualities of successful surgeons who encounter minimal complications. Although Dr. Canes concedes that technical skills are important, he thinks that the surgeon mindset is just as important. He emphasizes the importance of approaching surgical procedures systematically, breaking every big step down into smaller microsteps for precision. For difficult cases, he encourages surgeons to engage the opinion of trainees, PAs, and nurses in the OR. In these situations, he believes that patient outcomes should take precedence over pride and ego. Additionally, he highlights the importance of controlling emotions, heart rate, and respiratory rate during complications in order to think rationally.Finally, the doctors discuss the benefits of collaboration and co-operating. Dr. Canes encourages surgeons to stop by different ORs in order to learn new techniques.

Dr. Neil Desai, a radiation oncologist with UT Southwestern, shares his perspectives on radiation therapy indications, algorithms, side effects, and prognoses for unfavorable intermediate risk prostate cancer patients.---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/E4pmfO---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Neil Desai, a radiation oncologist from UT Southwestern, about radiation therapy indications, algorithms, side effects, and prognoses for unfavorable intermediate risk prostate cancer patients.Intermediate risk prostate cancer is defined by a Gleason grading score of 7 or more and a PSA level above 10 ng/mL but below 20 ng/mL. Radiation therapy is a common unimodal or multimodal therapy in these prostate cancer patients. Dr. Desi recommends additional imaging via MRI to stage the cancer before starting treatment. Additionally, bone scans and colonoscopies may be beneficial in order to find metastases and colon cancer, respectively, that can also be treated with radiation therapy (RT).A thorough patient history is important to obtain before choosing a radiation therapy option. Dr. Desai divides his history into 2 different categories-–patient-specific factors and disease-specific factors. For patient-specific factors, baseline urinary symptoms, metabolic disorders, hormonal disorders, patient preferences, and baseline sexual potency are important. Contraindications under this category include connective tissue disorders, ulcerative colitis, and Crohn’s disease. Prostate anatomy, such as large median lobes, also need to be assessed. Dr. Desai emphasizes that many of these contraindications do not totally rule out the possibility of radiation therapy, but just warrant careful consideration of the intensity of radiation used on the patient. Next, he discusses disease-specific factors, such as the efficacy of androgen deprivation therapy (ADT). The majority of prostate cancer patients are started on ADT for 4-6 months first, and then begin RT.Next, Dr. Desai summarizes his explanation of RT to his patients. He starts by delineating the differences between internal and external RT, which exist on a continuum. Based on which RT option the patient chooses, the acuity and duration of lower urinary tract symptoms (LUTS) will vary. The RT option he most commonly recommends to patients without contraindications is brachytherapy with an external beam, which results in less cancer recurrence but more LUTS. However, he acknowledges that brachytherapy may not be offered in all centers, may have reduced efficacy in big prostates, and may be an unfavorable choice in patients with severe LUTS. In these cases, conventional fractionation, hypofractionation, or ultra hypofractionation are better options. Furthermore, Dr. Desai dives into more technical aspects of RT, such as the importance of a full bladder as a form of protection from external beam RT and the superiority of photon-based RT over proton-based RT. Additionally, he recommends measuring PSA levels after 3 months post-RT to minimize the chance of picking up noise. He mentions that physicians should address the “PSA bounce”, a fluctuation of PSA level post-RT followed by a transient resolve, with their RT patients because it may be a source of patient anxiety.Finally, Dr. Desai highlights the importance of the collaboration between urologists and radiation oncologists. The patient should be made aware that both specialties are in communication and feel comfortable discussing treatment options with both sides. Dr. Desai will usually advise his patients to meet with their urologists before making a final decision on their radiation therapy. Also, it is important for both sides to coordinate any new tests and check in periodically with patients.

Dr. Davies shares his valuable insights about post-operative opioid studies, disproves some myths about NSAIDs, and explains his pre-operative and post-operative pain management regimen.---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/XyDsiw---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Ben Davies, Director of Urologic Oncology at the University of Pittsburgh Medical Center, discuss non-opioid approaches for post-operative patients.First, Dr. Davies discusses diversion as an indirect problem with prescribing too many opioids because many urologists forget that patients with opioid prescriptions can have family members and close contacts who have access to these pills as well. According to Dr. Davies, data shows that post-operative urologic surgery patients have a rate of addiction of 1-2% when prescribed opioids. In his opinion, most patients who undergo urologic procedures, such as cystectomies, TURPs, and partial nephrectomies, do not need narcotics for post-operative pain management. Prospective studies done in the general surgery and urological surgery field prove that there is no difference in satisfaction between patients who manage their pain via non-opioid and opioid approaches. Furthermore, opioids may cause idiosyncratic results in post-operative patients, such as anxiety and GI problems.Next, Dr. Davies disproves some myths about NSAIDs. He does not agree with the practice of holding off NSAIDs for a week post-operatively, Also, he sees no problem with giving oral Tylenol to NPO patients. He strongly believes that bleeding risk and kidney damage as a result of toradol is minimal, and explains that creatinine levels always rise a bit post-operatively. He encourages urologists to walk their patients through the post-op pain regimen before surgery and to have pamphlets ready for distribution. Dr. Davies explains that for the most part, patients understand that opioid-related mortality deaths are rising and that 90% fentanyl and heroin users start with opioids. He also discourages doctors from prescribing extra opioid pills to patients.Then, Dr. Davies explains his pre-operative and post-operative pain management regimen. Pre-operatively, he uses Tylenol, gabapentin, and celebrex. Intraoperatively, he uses IV ketamine, propofol, and precedex. As patients are waking up from surgery, he will give toradol. Post-operatively, he will prescribe Tylenol and Motrin. Finally, he emphasizes the need for buy-in from the hospital administration for a non-opioid approach. He discusses the importance of meeting with hospital administration and nurses to change the pain management culture of an institution. In his personal experience, he made a quality improvement project out of his non-opioid approach and figured out his personal strategy towards pain management before presenting it to his department.---RESOURCESPekala KR, Jacobs BL, Davies BJ. The Shrinking Grey Zone of Postoperative Narcotics in the Midst of the Opioid Crisis: The No-opioid Urologist. Eur Urol Focus. 2020 Nov 15;6(6):1168-1169. doi: 10.1016/j.euf.2019.08.014. Epub 2019 Sep 26. PMID: 31563546.Yu M, Davies BJ. Opium Wars to the Opioid Epidemic: The Same Narcotics Cause Addiction and Kill. Eur Urol. 2020 Jan;77(1):76-77. doi: 10.1016/j.eururo.2019.10.006. Epub 2019 Nov 8. PMID: 31711720.“Dreamland” by Sam Quinoneshttps://samquinones.com/dreamland“The Least of Us” by Sam Quinoneshttps://samquinones.com/theleastofus

Aditya Bagrodia (UCSD Urology), Dr. Casey Seideman MD (OHSU Urology), and Dr. Jeff Cadeddu (UTSW Urology) share their experiences and advice for dealing with complications as surgeons.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/chwg66 ---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia (UCSD Urology), Dr. Casey Seideman (OHSU Urology), and Dr. Jeff Cadeddu (UTSW Urology) discuss their experiences and advice for dealing complications as surgeons.First, the doctors talk through dealing with complications in the operating room. The doctors emphasize the importance of maintaining a composed appearance in a state of urgent need and preparation for adverse events. For expected complications like blood loss, the surgeon can set up tools to deal with an adverse scenario, such as suction and communication with anesthesia. Furthermore, it is important to teach trainees to go through all the possible post-operative complications and develop a strategy to detect and manage them. For unanticipated issues, Dr. Cadeddu believes surgeons should think about why they did not think of and prepare for the outcomes, which is often a problem of infrequent exposure to a type of complication.Next, the doctors discuss how to deal with feelings of self-doubt and guilt after a complication has occurred. Dr. Seideman has learned to allow herself to acknowledge these negative emotions, as they are normal feelings; similarly, Dr. Cadeddu urges surgeons to keep their sense of empathy. Both doctors agree that having someone to talk to after adverse outcomes is important, whether it be an attending, a colleague, the department chair, or even a family member. They agree that morbidity and mortality boards are important, but do not have therapeutic value.Finally, the doctors talk about the importance of using institutional resources for support, such as other colleagues, support groups, and mental health hotlines.

In this episode of BackTable Urology, Dr Jose Silva and Dr. Esther Han discuss diagnosis and management of interstitial cystitis in women.---CHECK OUT OUR SPONSORDI4MDsProtect your most valuable asset, the skill and ability to practice your medical specialty. Be prepared by establishing a specialty specific disability insurance policy from the experts at DI4MDs. Contact them today at www.Di4MDS.com or call 888-934-4637.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/raFQdU---SHOW NOTESIn this episode of BackTable Urology, Dr. Jose Silva and Dr. Esther Han, a FPMRS physician specializing in bladder and pelvic floor health, discuss diagnosis and management of interstitial cystitis in women.Firstly, Dr. Han explains her workup of patients with suspected interstitial cystitis (IC). Because an accurate diagnosis of IC is so rare, she sends out multiple questionnaires to her patients before their appointments and performs thorough physical exams. Upon physical examination, other conditions may appear to be more likely than IC, such as genitourinary syndrome of menopause (GSM), lichen sclerosus, vaginal atrophy, or vulvodynia. She always assesses the pelvic floor to look for hypertonicity and knots. Another common cause of bladder pain is overactive bladder (OAB) and recurrent urinary tract infections (UTI), for which she can prove with a positive bacterial culture. Aside from the physical exam, she also gets a post-void residual urine test and a urinalysis. IC falls into two subtypes–IC with Hunner’s lesions and IC without Hunner’s lesions. The latter subtype is more common and is rarely seen in younger patients and patients with frequency symptoms. For this reason, Dr. Han does not regularly perform cystoscopies on young patients. Additionally, many patients with bladder pain will not be able to tolerate a cystoscopy procedure, so she relies on the physical exam and a health history to make a diagnosis.Treatment for bladder and pelvic pain is multimodal–many of her patients will work with physical therapists and pain management physicians for their chronic pain. Her first-line therapy for bladder pain is pelvic floor physical therapy, although the pain may get worse before it improves with therapy. She also recommends suppository vaginal Valium if needed, but thinks that more research should be done on suppository CBD. She does not prescribe opioids for pain management. If the patient has vulvodynia, hormone therapy with estrogen/testosterone creams is her chosen treatment. She notes that it is important to explain to patients that local application of estrogen does not increase their chance of developing breast cancer.Her second-line therapy includes amitriptyline, for anxiety-driven IC, and IC cocktails, which should only be continued if the patient’s symptoms are improving. Her third-line therapy is repetitive hydrodistention, but she only performs this procedure in patients with Hunner’s lesions. Additionally, Cyclosporin A should only be used exclusively in patients with Hunner’s lesions. If the patient is experiencing concurrent pudendal pain, Stimwave pudendal neuromodulation is a possibility. Dr. Han uses clues, such as pain while sitting down, excessive standing, and pain relief when laying down to diagnose patients with pudendal pain. Her last resort to bladder pain is a cystectomy, or complete removal of the bladder. She notes that this method is not very effective, as patients may experience phantom pain. For this reason, she makes sure to explore all other options and thoroughly counsel her patients before performing this procedure.Finally, Dr. Silva and Dr. Han discuss the evidence-based correlation between bladder pain and sexual abuse. Dr. Han encourages urologists to create a safe space for their patients to share their experiences and get quality referrals to counselors.

We talk with Dr. Scott Eggener about the importance of practical PSA screenings and shared decision making with patients. Dr. Eggener advocates for the prevention of overdiagnosis and overtreatment in prostate cancer.---CHECK OUT OUR SPONSORDI4MDsProtect your most valuable asset, the skill and ability to practice your medical specialty. Be prepared by establishing a specialty specific disability insurance policy from the experts at DI4MDs. Contact them today at www.Di4MDS.com or call 888-934-4637.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/3lPz2L---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Scott Eggener, director of the High Risk and Advanced Prostate Cancer Clinic at UChicago Medicine, discuss the importance of practical PSA screenings and shared decision making with patients. Dr. Eggener advocates for the prevention of overdiagnosis and overtreatment in prostate cancer.First, the doctors shared their approaches to prostate screening in a high risk patient. Dr. Eggener considers patients to be at high risk for prostate cancer if they have a positive family history of prostate, breast, ovarian, or pancreatic cancer. Also, the risk of developing prostate cancer is higher in patients with African and Ashkenazi Jewish ancestries. For high risk patients, he recommends annual PSA screenings but rejects the notion of a concrete threshold number. Instead, Dr. Eggener recommends comparing PSA screening values to the patient’s original baseline PSA value. He emphasizes that because the majority of prostate cancers are slow growing, a rapidly rising PSA can mostly be attributed to infection, inflammation, or another inciting event. For this reason, he always performs a repeat PSA screening a couple months after the initial abnormal test is obtained.In healthy patients with no family history of cancer, Dr. Eggener recommends initial PSA screening between 45-55 years old. Additionally, a “normal” PSA value is age-dependent. He estimates that a value of 0.6 ng/ml is normal for patients in their 40s, while 0.9 ng/ml is normal for patients in their 50s. For any value above 1.5 ng/ml, he will perform a digital rectal exam (DRE) to gain more information about prostate size.In patients with an elevated PSA as well as an abnormal DRE, Dr. Eggener will obtain MRI imaging to look for prostatic lesions. If the MRI is clear and the patient has no other risk factors besides an elevated PSA, he will recommend PSA screening every 1-2 years. If the MRI shows prostatic lesions, he will continue with a biopsy. However, Dr. Eggener acknowledges that cancer may be a possibility in patients with clear MRI scans, as imaging can sometimes be inaccurate. Thus, he sometimes chooses to biopsy high-risk patients with normal MRI scans as well.Finally, the doctors discuss the advantages and disadvantages of new screening tools, such as Next-Generation biomarkers and polygenic risk scores, in diagnosing prostate cancer.

Dr. Jose Silva y Dr. Fernando Cabrera, urologista de Cleveland Clinic en Florida, hablan sobre el diagnóstico y tratamiento de cálculos renales y ureterales. Los doctores discuten cuáles pacientes necesitan la intervención, los métodos quirúrgicos para romper los cálculos, y consejos sobre cada tipo de terapia.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/gShnfX---CHECK OUT OUR SPONSORLaurel Roadhttps://www.laurelroad.com/healthcare-banking/---SHOW NOTESEn este episodio de BackTable Urology, Dr. Jose Silva y Dr. Fernando Cabrera, urólogo de Cleveland Clinic en Florida, hablan sobre el diagnóstico y manejo de cálculos renales y ureterales.Primero, los doctores discuten cuáles pacientes necesitan la intervención. Dr. Cabrera nota que la mayoría de pacientes pueden pasar un cálculo simple. Usualmente, cálculos pequeños y distales pueden ser manejados con medicamentos e hidratación, como una prueba de paso. Pero en casos más complicados–como en el caso de un cálculo obstructivo y proximal, un cálculo infectado, o una cálculo ubicado en un área difícil. Adicionalmente, Dr. Cabrera enfatiza que la sepsis es una emergencia y los urologistas deben observar por los síntomas de fiebre, altos recuentos de glóbulos blancos, e hipotensión. Dr. Cabrera prefiere usar el tomografia (CT scan) para visualizar los cálculos. Para un cálculo distal, es importante visualizar la pelvis también.Próximo, Dr. Cabrera comparte sus consejos sobre cada tipo de terapia. Para empezar, discute su método de una prueba de paso. Prescribe a su paciente Flomax y un NSAID y se reúne con el paciente periódicamente. Si el paciente no puede pasar el cálculo en cuatro a seis semanas o sufre de dolor nuevo, Dr. Cabrera hace un segundo estudio tomográfico de baja radiación y explora la intervención quirúrgica.Entonces, Dr. Cabrera discute los métodos quirúrgicos para romper los cálculos. No hace mucho la litotripsia por onda de choque, porque no es más eficiente que la ureteroscopia o PCNL en muchos de sus pacientes. Sin embargo, explica las tres opciones a cada paciente antes de escoger una terapia. Próximo, Dr. Cabrera describe los medicamentos preoperatorios y postoperatorios y sus herramientas (visores, fundas, láseres, etc.) y procedimientos para la ureteroscopia y PCNL. Curiosamente, nota que aunque usa el láser holmium y el láser thulium para litotripsia, prefiere el láser thulium porque es más bien organizado y provee buen enfoque. También, durante la ureteroscopia, usa el cable de seguridad en casos de cálculos complicados. En resumen, Dr. Cabrera y sus colegas tratan de evitar las nefrectomías cuando pueden.

We talk with urologist Dr. Jay Shah, leader of urologic oncology at the Stanford Cancer Center, about seizing leadership opportunities in the world of academic medicine.---CHECK OUT OUR SPONSORDI4MDsProtect your most valuable asset, the skill and ability to practice your medical specialty. Be prepared by establishing a specialty specific disability insurance policy from the experts at DI4MDs. Contact them today at www.Di4MDS.com or call 888-934-4637.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/voLZNT---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia interviews urologist Dr. Jay Shah, leader of urologic oncology at the Stanford Cancer Center, about seizing leadership opportunities in the world of academic medicine.First, the doctors discuss the importance of finding a niche for their medical practice and research. Dr. Shah encourages young faculty members to identify a specific interest within their field and start research related to that topic. Although it was hard for him to prioritize his niche at first, he realized that gaining knowledge in quality improvement, his chosen niche, was much easier when he merged both his clinical and academic work.Then, Dr. Shah and Dr. Bagrodia discuss the challenges of a mid-career change. Dr. Shah moved from MD Anderson to Stanford, while Dr. Bagrodia moved from UT Southwestern to UC San Diego. Both doctors agreed that changing institutional cultures and practices can be daunting; however, they noted that it was important to build credibility and to keep an open mind about listening to the ideas of their new colleagues. Dr. Shah believes that new faculty may take up to four years at their new institution before they start to feel comfortable in their new position. Dr. Bagrodia then warns against having unrealistic nostalgia for old institutions.Finally, the doctors suggest ways to build leadership skills and gain leadership experience within the field of urology. Both doctors found leadership courses and having an executive leadership coach helpful. They also encourage young urologists to get involved in committees of urological societies, including the American Urological Association.

We talk with Dr. Shahrokh Shariat, chairman of Urology at the Medical University of Vienna, about diagnosis and management of upper tract urothelial carcinoma (UTUC) as well as differing AUA and EAU approaches to these malignancies.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/OVNyKk---SHOW NOTESIn this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Shahrokh Shariat, chairman of Urology at the Medical University of Vienna, about diagnosis and management of upper tract urothelial carcinoma (UTUC) as well as differing AUA and EAU approaches to these malignancies.First, the doctors discuss common history and physical examination findings of patients with UTUC. Hematuria is the the most common sign, followed by flank pain and hydronephrosis. 10-15% of UTUC patients will also have Lynch syndrome, which is a condition that indicates a genetic predisposition to UTUC as well as other cancers. After initial hematuria workup, imaging of the upper tract and kidney must be obtained. Dr. Shariat obtains a CT urogram and an ultrasound for patients with suspected UTUC but waits until a tumor is identified to get a chest X-ray. Indirect signs of UTUC are: filling defects, thickening of the ureter wall, and hydronephrosis.Performing a ureteroscopy is the next step in UTUC patients. A ureteroscopy obtains adequate specimen for grading and reveals tumor behavior and location. A ureteroscopy can also be used as a therapeutic approach if kidney preservation is possible. Dr. Shariat uses a “no touch technique” in which he uses an access sheath to prevent tumor seeding. He prefers to use a flexible ureteroscope, a holmium laser, and a basket for collection. After ureteroscopy, he places a double J stent in his patients and waits for 6 weeks before taking a second look and starting alternating imaging, if needed.Surgical intervention may be required to treat non-metastatic UTUC. Dr. Shariat usually administers four rounds of neoadjuvant chemotherapy to his patient before operating. He recommends checking the patient’s renal function to see if cisplatin-based therapy can be tolerated. Dr. Bagrodia and Dr. Shariat then compare the outcomes of cisplatin and carboplatin-based therapy.Next, Dr. Shariat shares his tips for segmented ureterectomy. Although this procedure is relatively uncommon, he advocates for careful closure, intraoperative chemotherapy, and clipping the ureter above and below the tumor to prevent seeding.To end the episode, the doctors discuss new UTUC therapeutic options, such as JELMYTO, a gel-based chemotherapy administered through a catheter. Finally, Dr. Shariat emphasizes once more that UTUC is a heterogenous cancer that requires multimodal therapy.