Unless there is a finding on the contralateral ureteropyelogram, endoscopy is limited to the suspicious affected side. One of two “no touch techniques” is employed. This describes endoscopic inspection of the entire urothelium prior to any instrumentation. No guidewire which can traumatize the urothelium and the first and the earliest “no touch technique,” uses a small caliber rigid ureteroscope passed through the bladder and into the ureteral orifice under direct vision [83, 84]. The endoscope is advanced as far proximally as possible without excessive torque or angulation. Often in a female, the ureteroscope can be passed to the renal pelvis without difficulty, and the endoscope typically cannot be passed beyond the level of the mid-ureter at the iliac vessels in most patients. This initial passage of the radially dilating semi-rigid ureteroscope to inspect the distal and mid ureter mildly dilates the ureteral orifice and distal ureter and facilitates insertion of the flexible ureteroscope (FU). A guidewire is then passed through the rigid ureteroscope and left in place only to the most proximal level of the ureter inspected. The position of the wire is confirmed, both endoscopically and fluoroscopically. Strict attention should be taken to prevent inadvertent proximal migration of the wire. Dilation of the ureter should also be avoided to minimize trauma to the ureter from or the dilation itself. It is rarely necessary to dilate. Hudson et al. described that the ideal flexible ureteroscope outer diameter is 7.5 French (F) to minimize the need for ureteric dilation since <1 % of cases failed to pass using this size scope [85]. Flexible ureteroscopes from most manufacturers have increased in size to 8.3–8.5 F. Some digital ureteroscopes are even larger and may require dilation.

In the second “no touch technique”, the flexible ureteroscope is used alone without any initial rigid endoscopy. With the appropriate size ureter and flexible ureteroscope, it can be inserted directly into the ureteral orifice in a wireless, sheathless approach [86]. The flexible ureteroscope is passed through the urethra and bladder and then directly into the ureteral orifice. It is passed throughout the ureter to inspect the entire mucosa and then into the intrarenal collecting system.

As with the rigid technique, vision must be maintained through the passage of the flexible ureteroscope. Any small ureteral tumors are biopsied and treated as they are encountered using the techniques described below (Fig. 1.2). Such small lesions at 1–3 mm may be avulsed with scope advancement and be lost or possibly induce bleeding. Therefore, they are treated as they are encountered. If, in comparison, a large lesion is found, it may be helpful to advance the ureteroscope beyond the lesion into the more proximal ureteral segment to identify other tumors.

With larger tumors such as those that fill the lumen and may extend 1–2 cm beyond the base (e.g. Fig. 1.1), it may be difficult to identify the ureteral lumen itself to get past the tumor. It may be useful to follow the contour of the ureteral wall or, in select cases, pass a hydromer coated guidewire beyond the tumor to gain proximal access. Although a “no touch technique” is preferred, a guidewire is used whenever it is needed to ensure access.

Next, the ureteroscope is advanced into the renal pelvis. An aspirate of urine is obtained and sent for cytology. This is completed by connecting a large (50–60 mL) Luer lock syringe directly to the irrigation port (Fig. 1.3). Avoid touching the pelvis and certainly avoid aspirating against the mucosa to avoid traumatic bleeding. The collecting system is then inspected systematically. First the entire pelvis is seen and then the intrarenal collecting system. Since severe deflection may be required to reach lower pole calices thus inducing bleeding, inspection should proceed from the renal pelvis to the upper, mid and finally the lower calices.

Any tumors seen within the renal collecting system are biopsied and possibly treated at the end of the inspection. Various devices have been introduced to biopsy upper tract tumors, including baskets, forceps, brushes, snares and graspers. The most successful and most commonly used devices are the 3 French cup biopsy forceps and the stainless steel flat wire basket [87] (Fig. 1.4). The cup forceps are available in several designs of 1 mm diameter. These are well suited for sampling smaller papillary lesions, sessile or flat lesions. If the sample is entirely contained within the cup, the device can be withdrawn through the working channel. The device is then replaced through the ureteroscope and multiple samples are taken in a similar fashion to ensure a sufficient specimen for cytologic evaluation. If the tissue fragment extends beyond the cup, the entire unit consisting of FU, forceps, and biopsy specimen should be removed from the collecting system to preserve the largest specimen possible. The endoscope is then replaced and additional biopsies are obtained.

Depending on the ureteroscope employed and cup forceps, the device may limit the deflection to only 90–100° [82]. This may prevent positioning to biopsy lower pole lesions.

The stainless steel flat wire basket is quite effective for more sizable, papillary, and friable tumors [83, 87]. The tumor is visualized and the basket extended and applied to the tumor itself. It is manipulated to bury the wires into the tumor and the basket is then closed snugly but not completely, which would cut the sample from the basket. It is used to avulse a piece of tissue. In this way, a large sample measuring up to several millimeters may be retrieved. These larger samples should not be withdrawn through the working channel since most of the tissue would be sheared off and lost. Instead, the entire unit consisting of FU, basket, and biopsy should always be withdrawn to maintain the largest tissue specimen possible (Fig. 1.5). The FU is reinserted and multiple biopsies are taken. With this flat wire technique, large tumors up to several cm in diameter can be mechanically debulked quite effectively. Kleinmann et al. compared the flat wire basket and cup biopsy forceps for the success rate of diagnosis and grade determination of UTUC. Diagnosis was successful in 63 and 94 % (P < 0.0001) and specific grade was determined in 80 and 93 % (P = 0.033) in the forceps and basket groups, respectively. On subgroup analysis of tumors larger than 10 mm in diameter, the flat wire basket was still shown to be superior in achieving pathologic diagnosis (P = 0.037) [87].

Other devices are relatively ineffective and are rarely used in our practice. The nitinol round wire baskets, described as atraumatic, do not have enough grasping edge to capture tumor well. The brush is also very poor in retrieving tissue. When it is viewed directly endoscopically, the brush can be seen moving the tissue but not actually sampling it. It should be recalled, however, that cystoscopic placement of the brush to a filling defect improved sampling and diagnostic capability over voided urine alone [49]. Wire pronged graspers cause less loss of deflection with the flexible ureteroscope and may be used to sample tumors in the lower pole. However, the device cannot adequately sample or retrieve the tissue. More often, the prongs will tear off bits of the tissue which may be able to be retrieved by aspirating through the channel of the endoscope.

Recently, a cup forceps with a larger 2 mm cup has been introduced. Because of the size of the cup, the device must be back-loaded through the working channel of the FU. Subsequently, the flexible ureteroscope with the back-loaded forceps must be placed through a ureteral access sheath. If this technique is employed, we strongly recommend inspecting the ureter first with a “no touch technique” to evaluate for ureteral lesions prior to placing the access sheath. Next, it will be noted that the large cup forceps obscure the visual field. This device appears to have a more flexible shaft which allows better deflection. Although the sample achieved with the 2 mm forceps is greater than with the 1 mm, it is much smaller than that which can be retrieved with a flat wire basket.