Wireless no-touch flexible ureteroscopy with the new flexible instruments is a feasible and safe technique for diagnostic and therapeutic procedures in most patients, irrespective of the location of the pathology, including the distal ureter. These ureteroscopes, with their exaggerated deflection, are ushering in a new era of endoscopic treatment of the upper urinary tract. Greater instrument deflectability and control can lead to shorter procedures and fewer treatment failures.

OBJECTIVE To evaluate the results of the retrograde endoscopic treatment of upper urinary tract urothelial malignancies (UUTUM) in an attempt to preserve renal function while also obtaining an acceptable oncological result. PATIENTS AND METHODS Since 1995, 63 patients who were referred for retrograde endoscopic management of UUTUM were evaluated and treated. All patients had an initial diagnostic ureteroscopy and biopsy to obtain histopathological grading. Additional imaging studies were obtained to exclude metastatic disease. The treatment was directed by tumour grade at presentation and medical comorbidity. Tumour volume and multifocality did not exclude patients from vigorous endoscopic treatment. Tumours were resected with electrocautery, holmium‐YAG and Nd:YAG laser. Follow‐up endoscopic surveillance was initially at 3‐month intervals, with increasing intervals in patients with repeatedly negative findings. RESULTS The tumour grade at presentation was high in 14 (22%), moderate in six (10%), low in 35 (55%) and carcinoma in situ in eight (13%), with 13 (20%) presenting with or subsequently developing bilateral disease. Twenty patients had a nephroureterectomy as they were not amenable to endoscopic treatment. Medical comorbidities necessitated palliative endoscopic therapy of high‐grade tumour in six patients; the remaining 35 had low‐grade tumour and were managed with retrograde endoscopic therapy. Recurrent low‐grade disease was identified in 24 with a mean (range) time to recurrence of 15 (3–63) months. There was concurrent low‐grade bladder cancer in 21 (60%) of the patients. The mean (range) follow‐up was 32 (3–84) months. No patient with low‐grade tumour progressed in grade or stage, and all but one who presented with high‐grade tumour progressed. CONCLUSION The retrograde endoscopic management of UTTUMs is particularly useful for patients who present with low‐grade lesions, providing good oncological control and preserving renal function. These patients require a careful and consistent follow‐up, as many will develop recurrent disease. Treatment of higher‐grade lesions is at best palliative.

The arrival of the flexible ureteroscope has been of great value to urologists, allowing access to virtually all parts of the collecting system. Authors from two centres in the New York area and Taiwan write in this section about their experience with new types of flexible ureteroscopes. Their views are sure to be of interest to readers.OBJECTIVETo increase the clinical usefulness of the actively deflectable flexible ureteroscope by making sequential changes in design and then using these prototypes clinically; and to develop a clinical series using the optimum prototype and contrast it with an extensive database of patients treated with the traditional flexible ureteroscope.METHODSA series of prototypic flexible ureteroscopes was developed and used clinically. The active deflection of the prototype ureteroscope was evaluated with and with no accessories in the working channel, and compared with a standard 7.5 F ureteroscope. Clinical data were then accrued and compared with a previously published database.RESULTSThe progression of prototypes led to a final version which incorporated > 300° primary active deflection, shaft miniaturization (8.4 F) and an increase in endoscope shaft stiffness. The prototype flexible ureteroscope had significantly greater active deflection than the standard ureteroscope, especially when working channel accessories were used. In all, 115 endoscopic procedures were carried out, the indications for which included endoscopic lithotripsy for distal calculi (51), treatment of upper tract urothelial carcinoma (27), diagnostic endoscopy (26) and retrograde endopyelotomy (three). No guidewire was required to place the flexible ureteroscope into the upper urinary tract in 27% of patients. Active intramural dilatation for access was only required in 3% of the procedures. All lower pole calyces were accessed with this instrument.CONCLUSIONSAdding exaggerated deflection is a timely advance in flexible ureteropyeloscopy. This and the other changes in design facilitated complex retrograde endoscopic procedures and increased the therapeutic potential of the instrument.