Editing AUA: Upper Tract Urothelial Carcinoma (2023) (section)

==== Technical considerations ====
* '''Approach'''
**'''May be accomplished via a retrograde or antegrade percutaneous approach'''
***Antegrade approach typically reserved for
****Larger tumors 
****Tumor difficult to access in a retrograde fashion 
****Patients who have undergone prior radical cystectomy or urinary diversion 
*'''Tumor size'''
**'''Tumors < 1.5 cm in size may be optimal for endoscopic ablation given a lower risk of invasive disease.'''
***Tumors ≥ 1.5 cm in size are associated with a > 80% risk of invasive disease
***'''Larger tumors (≥ 1.5 cm) may be considered for ablation based on the provider’s experience and assessment of the need for kidney sparing surgery.'''
*Energy source
**Thulium laser, holmium laser, Neodymium (Nd:YAG), and electrocautery devices (e.g., Bugbee) may all be deployed through an endoscope.
*Chemoablation 
**May be employed either through retrograde ureteral catheter instillation or percutaneous access with fluoroscopic imaging guidance
*Ureteral access sheath
**Prior to placement of any ureteral access sheath, the entire ureter should be directly visualized in order to avoid missing any luminal neoplasms, especially in the distal ureter
**Advantages (3):
**#Allows for repeated scope passage up and down the ureter for sampling
**#Means of fluid egress from the upper tract to avoid excess pelvicalyceal hydrostatic pressure from irrigation solutions
**#Lower rate of intravesical recurrence (based on observational study)