Thulium Fiber Laser-Assisted En-Bloc Resection and Ablation of Renal Pelvis Tumors in a High-Risk Post-Cystectomy Patient: A Technique Guide for Novice Endourologist

Introduction and Objectives: Upper tract urothelial cancer (UTUC) occurs in 0.75%−6.4% of patients after radical cystectomy for bladder cancer. Radical nephroureterectomy (NUT) is the gold standard for high-grade, organ-confined UTUC; however, minimally invasive alternatives are considered for high-risk patients. While en bloc resection of bladder tumors has gained attention, there is no report of en bloc resection for UTUC. We present a technique using thulium-fiber laser en bloc resection of a renal pelvis tumor in a high-risk patient with an ileal conduit. Methods: An 81-year-old underwent robotic-assisted radical cystectomy with ileal conduit diversion 6 years ago (Bricker anastomosis). During surveillance, a computed-tomography-urography revealed nodularity in the renal pelvis and proximal left ureter, suggestive of UTUC. The patient had multiple comorbidities, with a Charlson-Comorbidity-Index of 10 points. She declined NUT and opted for endoscopic resection. Ureteroscopy through the ileal conduit revealed multiple papillary tumors at the ureteropelvic junction, posterior renal pelvis, and lower-pole calyx. Using a 200-micron thulium fiber laser (1 J × 10 Hz), en bloc resection was performed. The video demonstrates our surgical technique in detail. Results: Complete resection of the tumors was achieved in a bloodless manner. The patient had no intra- or perioperative complications and was discharged the same day. At the 2-week follow-up, she remained asymptomatic and successfully removed her stent. Pathology confirmed noninvasive high-grade papillary UTUC. She is scheduled for multidisciplinary management with a medical oncologist. Her follow-up ureteroscopy at 3 months revealed no tumor recurrence. Conclusion: Thulium fiber laser assisted en-bloc resection is a safe, feasible approach for endoscopic management of UTUC. Music: Soundtrack from Canva Popular Music Library ( https://www.canva.com/policies/popular-music-license/ ). Patient Consent Statement: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure. The authors have no conflicts of interest to disclose related to the publication of this work. The authors received no external funding for this work. Runtime of video: 4 mins and 50 secs.