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BackTable / Urology / Podcast / Transcript #35
Podcast Transcript: Diagnosis and Management of Upper Tract Urothelial Carcinoma
with Dr. Shahrokh Shariat
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. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) History and Physical Exam Findings for Upper Tract Urothelial Carcinoma
(2) Imaging and Cytology for Upper Tract Urothelial Carcinoma
(3) Chemotherapy and Immunotherapy Considerations for Upper Tract Urothelial Carcinoma
(4) Obtaining Biopsies for Upper Tract Urothelial Carcinoma
(5) Ureteroscopy Technique for Upper Tract Urothelial Carcinoma
(6) Kidney Sparing Approach for Upper Tract Urothelial Carcinoma
(7) Jelmyto Therapy for Upper Tract Urothelial Carcinoma
(8) Partial Ureterectomy for Upper Tract Urothelial Carcinoma
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[Dr. Aditya Bagrodia]
Hello everyone. And welcome back to the backtable podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Aditya Bagrodia as your host this week, and I'm very excited to introduce our guest today. Shahrokh Shariat from the university of Vienna, where he is the chairman and professor. Thanks for joining us on the show, Shahrokh, how are you doing today?
[Dr. Shahrokh Shariat]
Thank you so much. Thank you Aditya. Thank you for having me with you.
[Dr. Aditya Bagrodia]
Excellent. Well, I think, you know, certainly from my perspective, when I think about upper tract, urothelial carcinoma, kind of goes hand in hand with Shahrokh, you know, really, I would say paradigm shifting collaborations in the early 2000s with the upper tract urothelial carcinoma collaborations, which not only shed so much light on this orphan disease, but in many ways kind of changed the way that we do collaborative research for rare tumors. Can you just comment a little bit on that experience for us Shahrokh?
[Dr. Shahrokh Shariat]
Thank you, Aditya. Actually, you know, the whole story about upper tract just happens. Like every story that we have in urology where we have a rare entity and not enough data from large prospective trials or well-designed prospective collection of data to make a decision. So it, I can, you know, clearly remember the day I was on call and I was Vitaly Margulis on call and we were sitting there and waiting for a patient to go to the OR at the VA. And we're thinking, and I was asking my question about upper tract and he was giving me, you know, he's a brilliant guy. He was giving me the answers from the textbooks. And I was sort of unhappy with the answers because the data that I was reading was not consistent with the textbooks and so on because they were all based on small retrospective single center cohorts. So we came up with, at that night, it was a Saturday night with a real thing. We're going to change this disease and we gotta do something to really impact it.
And based on a previous experience that I have, uh, with, uh, several mentors, building multicenter data sets, retrospective to answer questions, I took that experience and tried to reach out to many friends across the globe that I met in academic world to create a, sort of a retrospective data set of their experience, their management, and to try to understand what are the key issues in that disease. What I think has been the most incredible experience is, a lot of people have come together. We have shed light on a lot of dark areas in management of upper tract or understanding of upper tract. But obviously we have fallen short of our, a lot of, important questions because they need to be addressed with prospective studies and molecular analysis and so on.
But I think by putting the light and focusing a little bit on this disease entity, suddenly it became an important disease entity. You go to the EAU meeting, you have full poster sessions and lecture series on upper tract. It seems like it is such a high prevalence disease. It isn't, but it shows you that by creating research and shedding light, increasing awareness, a lot of more brilliant people will come, and investigate and make a difference. It has been an incredible thing because I've met more people than ever before through that. And the research has been really more fulfilling and friendships have been created.
[Dr. Aditya Bagrodia]
Yeah, and I mean, that's absolutely a part of it. Well, so I'm gonna take advantage of the time that we have to really kind of pick your brain from A to Z. So when patients are coming in, generally my experiences, and I think the data suggests that, typically it's going to be a hematuria evaluation that shows something in the upper tract. Let's just start out with, you know, basics. What are the critical parts of the history and physical exam when you see a new patient with upper tract disease or suspected upper tract disease?
(1) History and Physical Exam Findings for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
Aditya, you're absolutely right. Look, the most common sign for upper tract. urothelial carcinoma is hematuria, as you know, it's well-written, but it could be as flank pain or something from a lesion in a ureter, blocking the outflow and creating hydronephrosis in some symptoms that are similar to that. Most patients get a workup for hematuria as a standard workup. And we know these have all the flaws as we have seen in women and men and women getting delayed referrals for hematuria workup, and male a little bit earlier. And part of that workup, you know, in the United States, you have a clear workup strategy. We have cystoscopy, cytology and upper tract imaging, which has been consistent with CAT scan with delayed cuts, right? In Europe, the workup is often associated with an ultrasound, as urologists are using an ultrasound and seeing their hydronephrosis or some less clear signs of an upper tract tumor.
If nothing is found in the bladder, you have a CT scan with a reflex test with delayed cuts urogram phase. Also a part of the workup is a history that is very important for upper tract that is often forgotten I think for me, is the patients with Lynch syndrome. So it's patients that have a family history of Lynch syndrome. And you know, you have the Amsterdam type two criteria that we use for identifying those patients. So that is basically a patient that as a personal history of Lynch syndrome that is generally younger than 65 years, or has a first degree relative, less than 50 years old with Lynch syndrome or has two first degree relatives. So I ask that always at every patient that shows up with hematuria, because that would trigger me a little bit, to be more suspicious of upper tract, which is, you have somewhere estimated 10 to 15% of the patients with upper tract having some Lynch syndrome spectrum disease. The other thing that is very important for me is the background of the patients, which in Europe, has to do with the Balkan endemic nephropathy exposure, and in the United States, you certainly have the Chinese herb exposure. So there are still [inaudible]. These are part of some Chinese herbs that are used in traditional Chinese medicine. And, they increase your risk of having sort of a DNA adduct and creating a higher risk for upper tract urothelial carcinoma. We have it here as part in the Balkans, tributaries of the Danube, you know, whole villages that have been exposed to that in a natural bread consumption, grain consumption while they cut these. So this is another exposure factor that you would look. Otherwise, standard workup, I would say.
[Dr. Aditya Bagrodia]
Yeah, I wholeheartedly agree. I mean, I impressed to the residents and fellows, at least endometrial cancer, colon cancer, upper tract cancer history. And not only for the screening of these patients, but should they go on to develop more aggressive disease, metastatic disease, if they have MSI, microsatellite, instability that could predict, of course, an excellent response to a checkpoint inhibitor, for instance. So I think that I actually will reflexively send all upper tract patients for medical genetic counseling. Or if that doesn't happen at the very least request the pathologist to perform MSI testing. Is that similar to your practices in Vienna?
[Dr. Shahrokh Shariat]
Look it is always two questions. I actually agree that's what we do standard, but I think for a university setting, something is easy, accessible, and easily manageable, I think for the community setting or for a lot of the colleagues out there that don't have that easy access to an expert pathologist or the resources to do that. I think at least the Amsterdam criteria for identifying patients at risk could be the first area where they can identify the 15 to 20% patients. It is wide catch. So they will identify the patients, but in an ideal setting, I would do the same thing on a pathology or get a genetic and germline testing as well.
The question, how does it change therapy? It is such a difficult concept because obviously even if they are MSI high, they're good responders to cisplatin based chemotherapy as well. And most of these tumors will sort of have a basal subtype. So it's very difficult to say, but certainly it opens in the United States because the pembrolizumab that has been approved for MSI high tumors to access to the drug. In Europe, it has not been approved for this setting. So it is less of a value for us here, but still I think, with most, we've delivered the therapy ourselves in Europe, that urologists give the therapy to checkpoint inhibitors as well as chemotherapy. We will consider it and talk to our hospital to allow that for that indication, as you mentioned.
[Dr. Aditya Bagrodia]
Excellent. Excellent. So ideally it sounds like when you're imaging the upper tracts, you're obtaining a CT urogram with excretory phases. Is everybody getting chest imaging?
(2) Imaging and Cytology for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
Well, not really. We don't do it unless you have the identification of a tumor. That makes sense. So it's always the CT urogram. MR Urogram in patients who, for some reason have poor renal function and you know, more and more patients today will refuse a CT because of a fear of higher radiation dose, is a second choice. But, it is more difficult to access in the United States. As mentioned, Germany and Austria, we use ultrasound quite often. Doesn't show us urothelial tumors, but at least it gives a first indication of if you have hydronephrosis as an in office tool to identify, but the CT urogram without imaging of the chest is standard for us also in the European guidelines.
[Dr. Aditya Bagrodia]
Okay. So you performed your office cystoscopy with no bladder lesions. And do you typically obtain a cytology at that time?
[Dr. Shahrokh Shariat]
Absolutely. We obtain a cytology and, you know, the cytology performance of cytology for lower track is highly variable depending on your cytopathologist and the method you obtain it. But its performance for upper tract lesions is even worse if you have divided cytology. Now, if you have selective cytology of both ureters with a wash, your performance, specifically, your sensitivity improves, but cytology in general is not a great task for upper track.
But we do it for the lower tract specifically to rule out carcinoma in situ, or other tumors that are not seen depending on if you use narrow band imaging, or you have already in office, some form of Hexvix imaging.
[Dr. Aditya Bagrodia]
So if you suspect that if your bladder is essentially clean and you have a positive cytology and some imaging suggesting an upper tract tumor, how does that factor into your next management, say high-grade cytology?
[Dr. Shahrokh Shariat]
It's a very important point. Number one, you want to make sure you don't have anything in the bladder. Certainly you could have something in the prostatic urethra, would be unlikely. Very rare tumors that happen there but could happen, and you would have seen a lesion during your cystoscopy that would be suspect, but then your question is to evaluate the upper tract and you're touching a key issue that, you know, one of the early articles was, if I remember well, an article that you've written, when you were a student, working with Jeffrey Cadeddu, right?
It was like, management of the upper tract, you know, conservative management and so on. So I think upper tract tumors similar to every cancer in urology has been suffering from one disease with two consequences. One is a monotherapy concept and the consequences are, under therapy in a lot of patients like now, systemic therapy. When they need it as a sort of a sandwich approach in invasive tumors and over therapy, in a lot of patients taking the kidney out, why it is a low grade tumor that could be managed or sometimes even a higher grade tumor that could be without papillary lesion. So for us, I think the weapon of choice, similar to the cystoscope, the cystoscope defined the specialty of urology. I think the ureteroscope is the next weapon of choice. Identifying the lesion and understanding what lesion it is, where it's located and, can, is it multifocal or not? Can I save that kidney, specifically in elderly, multi morbid patients, patients that are at risk for further kidney deterioration.
[Dr. Aditya Bagrodia]
Yeah, absolutely. So clearly when it comes to upper tract, you know, staging and grading and under staging under grading, misgrading, misstaging is kind of at the crux of this. Let's go back to the imaging. When you're looking at a CT scan, you know, what are the features that kind of puts you on high alert that this could be potentially a nasty tumor?
[Dr. Shahrokh Shariat]
Obviously, on the imaging, you have subtle signs and you have pretty significant signs and your radiologist will be similar to the Europe pathologist, your best friend in helping to identify those signs. You know, if you have a filling defect, obviously you're obliged to investigate.
It could be many things, right. But at least make sure it is not a cancer. If you have a filling defect and high-grade cytology, you know, some colleagues have been arguing, why do you ureteroscopy that may increase your intravesical recurrence rate through the manipulation of the tumor? I would still argue that you could have two events that are non-related, and there's strategies to lower the intravesical recurrence rate. If that is your worry. And it may not lead to such delay in effective, definitive therapy. But other signs are the thickening of the ureter wall or in the renal pelvis, hydronephrosis and stranding around the ureter. These are the I think the most difficult cases, these, you know, no papillary lesion. And you're thinking this could be some form of invasive tumor or carcinoma in situ of the ureter wall. That is very subtle. I think the CT scan itself or the MR scan itself, if you don't see a clear lesion or a filling defect on the urographic phase it is an indication to further investigate that region. It's not a clear sign of this is something going on.
[Dr. Aditya Bagrodia]
Right. right. I think, I mean, sometimes it's obvious if you have a tumor in the renal pelvis, for instance, that's clearly infiltrating into the parenchyma, you know, that's one where. I'd like to get your opinion on this, going back to the cytology. If you have an infiltrating mass with a positive cytology, is that a patient that you may consider? Let's just say neoadjuvant chemotherapy. Is that going to be information enough?
(3) Chemotherapy and Immunotherapy Considerations for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
Absolutely. So there are these cases where you have a positive cytology, right? And according to the Paris criteria, you're quite sure about it. You have a good uropathologist and you see clear lesion in renal pelvis that is integrated. So for me, this would have two consequences. That is enough for me to consider a patient for some form of systemic therapy. Now, the next question is what is his renal function? Is he able to get cisplatin based chemotherapy? And we have seen these type of patients where the tumor shrinks right after certain cycles of chemotherapy that you can switch to cisplatin, even if you don't believe cisplatin initially was the right fit. Couldn't get cisplatin. Now I want to put two important points there. These patients, the patient you described may not need ureteroscopy. I would feel comfortable with that, not to delay therapy. But number two, this patient is also highly likely to have lymph node metastasis. So I would definitely try to look at a CT scan and get a feeling how many cycles of chemotherapy do I really want to give three, four cycles? I would write a push to four. If I get six in yeah, dealer's choice, but at least it's good. Two years ago, I would say six cycles would positively influence no questions, definitive chemotherapy. Today based on studies, we've seen that maybe four cycles with the maintenance immunotherapy may be an option and interval maybe nephrectomy if you have a complete response, one could discuss that. And another concept I would like to, that has been really in the last year is, is carboplatin really that much worse than cisplatin in the upper tract. And look, I don't, I cannot say yes or no, it's based on [inaudible], you know, and you have some other data showing in cisplatin eligible patients, carboplatin may not perform as bad as we thought previously.
So I don't know how much that helps me further, but you've touched on a key point. And I think I know you very well. We come from the same school of thought you would consider neoadjuvant chemotherapy in this patient. There's literally no evidence for that, except, you know, the ECOG ACRIN prospective single arm trial, but, and then some retrospective data and we publish a huge retrospective cohort. You guys publish a huge three center retrospective cohort, showing that it may benefit. I think it is the right approach, but level one evidence shows that probably, an adjuvant strategy is based on level one based on disease free survival as an endpoint, which I don't think is an adequate endpoint for this disease; should be overall survival. But I believe in what you said, I would in a patient that is considered high risk, like high volume tumor high risk based on all the criteria as you've described and potentially even with positive lymph nodes, I would go for systemic therapy, first choice. And based on imaging response, then trigger a radical nephroureterectomy, based on the imaging response. If he's not cisplatin eligible, what are you going to do then? What do you think, Aditya? Would you give him carboplatin as a strategy based on the newer data?
[Dr. Aditya Bagrodia]
Yeah, I think you're absolutely right. You know, if you'd asked me three or four years ago, just the word carboplatin would kind of make me cringe and I wouldn't even consider it for a patient of mine, but I think there's, the Powell trial was compelling, and it is getting complicated. I mean, going back to like lymph node positive patients, as you mentioned, you know, it used to be six cycles of induction therapy, maybe restage them after three or four, see how they're doing and then consolidate them. I personally think that the approach that you described, four cycles, consolidate with surgery, and then adjuvant checkpoint inhibitors is more compelling. I haven't completely shed my biases against carboplatin. I think I would probably lean towards cisplatin ineligible approach for a checkpoint inhibitor, but these are, you know, these are the outstanding questions. And I also recognize I have my biases between Memorial, where Jonathan Coleman led a new regiment study and between UT Southwestern, whereas essentially high grade, upper tract urothelial carcinoma, you get neoadjuvant chemotherapy, almost no questions asked, cause you might miss this window where up to 60% of patients may be cisplatin ineligible.
So that's been the philosophy that I've subscribed to, but I recognize that you have this tour de force level one trial that just doesn't exist in the neoadjuvant. You've got your pathologic downstage and you've got your retrospective outcomes. You know, these MD Anderson series that are pretty compelling, but the same caliber data's not there, I suppose.
[Dr. Shahrokh Shariat]
And then the other question is also for me, you have to check 274, right. Looking at the adjuvant nivolumab and the upper tract tumors just don't perform as well as single agent adjuvant. Obviously, I don't think anybody in that trial got a neoadjuvant chemotherapy for the upper track. I think, I'm not sure that checkpoint inhibitors are as effective now based on, on the data looking at the basal type tumors in the upper tract, you would think, yes. And you have a high proportion of Lynch syndrome signatures that you see. Should be, but I think chemotherapy is still the way to go. And if you could get carboplatin in, instead of, if you have no choice, it is probably better, but I wouldn't use it neoadjuvant. I agree with you. I mean neoadjuvant and cisplatin is what we, but that's again, the major drawback we have, you're extrapolating from bladder cancer to the upper tract, still in a lot of decision-making key points because the data is just too weak despite all those efforts. but neoadjuvant, I think is a strategy that has been underused in upper tract, but I have to mention it will lead to significant amount of over-treatment even more than in a bladder cancer, probably.
[Dr. Aditya Bagrodia]
Yeah. I mean, two comments. I think there was this study, from the upper tract urothelial carcinoma collaboration from 2009 that showed if you actually just use cytology presence or absence of hydronephrosis, you would actually over-treat about 60% of the patients. So there's going to be some serious overtreatment. And then the other point that I would just like to make and hear your comment on. It does seem that there is a relatively higher proportion of FGFR3 mutations, even among patients with high-grade disease. And that could be another option for, you know, exploring FGFR3 inhibitors in this context.
[Dr. Shahrokh Shariat]
Yeah, this is, you've been involved in, there've been three or four key papers, I think in this area where we're looking at these scores. It's not only genetically, but epigenetically between lower and upper tract. And we've learned a lot about them and not only about the significance or the alterations, there are that differentiate these two diseases, but that are signatures specific to the upper tract. But you know, the preponderance of those alterations have triggered that, upper tract is really an FGFR3 driven disease to a large degree. And those therapies that we are already using in the second line, bladder cancer, metastatic second line bladder cancer, maybe good therapeutic strategies to use in upper tract early on if you identify an FGFR mutation or fusion. Now the question is if you're going to get Lynch syndrome signatures, why not get immediately FGFR? Because this is all about precision medicine nowadays, you know?
[Dr. Aditya Bagrodia]
Absolutely. One kind of question about these infiltrative masses. Do you have any opinions on percutaneous biopsies?
(4) Obtaining Biopsies for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
Yeah. Haha. When you and I were in training together, percutaneous biopsies were sort of, we don't want to do that because you're asking ureteroscopies, you know, became really a fashionable great thing. And we certainly were very scared and ureter carcinoma is such that the biopsy core could lead to metastasis or seeding there. So I wouldn't really see a big benefit if you can stay within the system. Right. But do I think it's a devil, as it used to be in the past? No, because our biopsy technique and everything has changed and I'm, I'm not sure, but the question is if we can get endoscopically to it, and if the cytology is negative and you can endoscopic to it because you need some tissue proof of the cancer before you deliver the therapy. I will try to go endoscopically and not get it by cutaneous biopsy, but I wouldn't feel as terrible as I used to feel in the past, I have to admit. What you think?
[Dr. Aditya Bagrodia]
Yeah, absolutely. I think, I mean, once upon a time, anything percutaneous, as it pertains to upper tract was anathema that, you know, you're going to get roasted. If it's an infiltrate of mass and say our oncologist really wants some tissue prior to treatment, I'm pretty much okay with it. I think with the coaxial techniques it's safe and the risk of seeding is fairly minimal. I wouldn't feel comfortable leaving a nephrostomy tube in. I don't like that strategy. I think the likelihood of seeding that track is pretty real, but older sicker patients save them an anesthetic, do it under local. I do think there's maybe a bit more of a role and a bit more of this kind of dogma surrounding upper tract. And I know this is kind of getting into the weeds on some of the practical things, but this is what, you know, these are the decisions we have to make, I suppose. So, you know, my, my stance is if it's infiltrative, you just need to get a tissue diagnosis. It's pretty reasonable. And as you're clearly aware, sometimes you go in and the imaging suggests there's going to be something super obvious and you don't see anything. And you know, whether that's growing extra luminally into the parenchyma, et cetera, can be a bit of a bit of a quandary.
[Dr. Shahrokh Shariat]
Absolutely. So I think what makes upper tract still a challenging disease, more these sort of, each time you intervene, each case is quite different and it's a low volume of cases and certainly there's cases where you really need to biopsy it. I agree with percutaneous access, um, and no percutaneous tube leaving behind, but at least biopsying it, I think that risk is very low for seeding. The question is if you're going to get a biopsy, you may get even a better specimen in the age of genetic sequencing may help your decision making in the next steps, not for the primary therapy, but maybe for a precision medicine approach. Probably this is going to be more useful in the future. Then, endoscopic, minute fragmented delivery that is not even good enough for your uropathologist to say what it is. And lo and behold, to tell us how to direct our therapy.
[Dr. Aditya Bagrodia]
So let’s hear your kind of approach. You've got a patient that you're going to take to ureteroscopy. First question. Is that first ureteroscopy in your mind, is that a diagnostic ureteroscopy is there therapeutic ureteroscopy potentially both. How do you approach it?
(5) Ureteroscopy Technique for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
It really depends, you know, on the clinical scenario, as you described, sometimes you have a clinical scenario where you just want to get specimen. And it looks for the imaging, pretty clear and [inaudible] is not positive or something. Then, you know, I would go up and say, I want to have as little manipulation as I can, or a little manipulation. And then obviously the large proportion of cases where we really believe we make a difference. Specifically, we do ureteroscopies that you get a specimen that is adequate for your grading, at least, you know, and get from the ureteroscopic diagnostic ureteroscopic some information about the tumor biology and behavior: multifocal, large, small, pedunculated, not pedunculated, sessile, you kind of want to get that feeling, location easy, how easy it is to access and all that. So you want to collect that information and often that is also , if you have the feeling, this is a tumor that I could consider for a kidney sparing approach, I would use it also as a therapeutic approach. You, so I'm always the therapeutic strategy with it. So I have the laser on standby for using it, not only for tissue acquisition, but also sometimes for obtaining the adequate specimen. And also my approach that, you know, is always a, sort of a no touch technique. I would go into the distal ureter and move up. You know, we all learned [inaudible]. So it is useful and they carefully monitor all the ureter below. I like to get an access sheath, to that. So I can go multiple times up and down after I've looked at their lower part, still in distance from the tumor and also with the concept of probably the seeding after my tumor manipulation coming through the access sheet out and not into the bladder.
[Dr. Aditya Bagrodia]
No, I think, I mean, I've actually thought about the, you know, these exact types of types of things, and for urines coming straight out of the meatus for the introitus versus spending some time in the bladder conceivably that could decrease the risk of lower tract recurrences. So you start out with the semi-rigid ureteroscope and, you know, basically just enter the distal ureter get up to the pelvis collecting system. And then you'll go back in, get an access sheath up and clear your renal pelvis. Is that right?
[Dr. Shahrokh Shariat]
Yes, not always. Now with the single use ureteroscopes, I just, many times I go with a flexible ureteroscope immediately in this, depending on if on imaging, I've seen a location of the tumor. If the tumor is in distal or mid ureter, I really prefer the semi-rigid as, as you mentioned, but if I see it's further up, I know I'm gonna, you know, use a flexible anyway, I gotta look at it and it is a single use instrument. Even if it wouldn't be a single use, probably would go with a flexible ureteroscope. The challenge is obviously, getting into the ureter and so on, but you could place the wire before. If you're worried and I try not to do that in cases where I want to look at carcinoma in situ, but if I've seen a papillary lesion, What am I looking for? So I'm not that worried about that wire making a red dot in my ureter. So this is the question and there's a strong school of thoughts, you know? One of our, the European gurus on this feels like flexible ureteroscope or you die. I feel like I don't understand why, because with a semi-rigid you get better specimens and everything, if you want to get specimens, right?
[Dr. Aditya Bagrodia]
I feel like I'm just getting older day by day. I love a semi rigid. I think it's a great instrument in the ureter in my hands. You know, you gotta know what you're doing, it can be dangerous. And I hear you a hundred percent. I mean, we have Manoj Monga here. You know, people who are just absolute whizzes with the flexible, ureteroscope. So, typically do you use a basket, a brush? What are your kind of tips and tricks for actually obtaining this coveted specimen?
[Dr. Shahrokh Shariat]
Yeah, I think, everybody who is doing it on a regular basis knows how frustrating it is. You know, it's obtaining a specimen and the pathologists not laughing at you and saying, what have you sent to me? So basically I make it dependent on the location of the tumor and how it looks. I like to get an adequate specimen for diagnosis specifically if I had a negative cytology, because it's gonna determine a T1 and higher or something, tumor like this that I suspect to be T1 and higher, or less, I really want to know what it is, Especially at tumor grade, to obtain an adequate specimen, you have to adapt your tools to the locations. If it's in a helix or like, a basket that is not like a circle basket or something that, that you don't get the papillary, you don't get too much bleeding for visibility. Otherwise I prefer, you know, some sort of a flat wire basket you have, something that can get the specimen off. I often use, before I do that, holmium laser to dissect it out, depending on location so I get an adequate specimen. I like, what Serena Mateen has shown me many years ago, the push technique. So I get the basket or whatever instrument you want, and you push the specimen in instead of pulling out and not tearing the specimen and ripping into pieces, you get a better specimen.
[Dr. Aditya Bagrodia]
I think I echo exactly what you're saying. I mean, starting out with, I think you need to be familiar with the tools, whether it's a Piranha, bigopsy, a brush, a basket. Basket's my go-to. And sometimes, when you take off the tumor, you do run into some bleeding, but you get a good specimen. I think that's manageable with the laser. The other thing that I do is after I do my biopsy manipulation, et cetera, I'll get a cytology at that point. I always send off a specimen, both as a cytology, as well as for pathology. So I try to do, you know, cover my bases as much as I can to get a diagnosis and be able to move forward.
But the ureters, extensively more tricky. Sometimes you see a stricture, et cetera, and you know, you can't obviously angle into it and I'll just take my time, whether it's three or four brushes or a Piranha, and doing the best that I can. I mean, it's always humbling when you think you've done something, you come out and there's, you know, a cell on your biopsy. And then for the brushes, I cut the brushes off and I send those both as a cytology and in a pathology.
[Dr. Shahrokh Shariat]
I think I'm laughing when he was telling this, because this is sort of their UT Southwestern school. I went through the same. Split your odds, get a cytology at least it makes so much sense. I absolutely agree with you. I try to always get a specimen for cytology. So before I start, I never thought about after, but it makes even more sense to get a selective cytology of that region. I mean, basically you look up, you do a retrograde, you get a selective cytology, you do a retrograde and then you move to a specimen and then it would be great to have a specimen. You know, whatever you need to use to get that specimen out. The armamentarium is getting better. I've never used a laser or something like that, but certainly would, the energy source would be good enough to dissect it out, but I really try to dissect a specimen out if I can.
[Dr. Aditya Bagrodia]
Fantastic. And, as you were kind of describing the input, when you're doing your ureteroscopy, size vocality, location, presence, or absence of carcinoma in situ, it just kind of occurred to me when I talked to the resident, there's been some very nice papers on standardized checklists and absolutely I think for, cause there is prognostic information from all of these clinical parameters that if you don't obtain them at the point of care, it's not like the next person is going to know exactly what transpired, but it's a thought and I guess what I'm getting at is, so you're making an assessment now, is this a tumor that's potentially managed with the kidney sparing approach? And maybe if you don't mind just kind of running through, you know, what that looks like in your practice.
(6) Kidney Sparing Approach for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
Absolutely. I think you touched on something. The idea doesn't come from us, you know, it came, I think the first one I've seen is it was Harry Hurr coming with this checklist concept. Right. And we know the checklist from everything and the checklists that have been introduced for patient safety in medicine, similar to other industries. So we have in [inaudible] invasive bladder cancer, because it's exceptionally important for your risk attribution and your therapeutic strategy. So our OR reports are very structured and these are the points that are important. Just tell me the key factors that will change my prognosis and my restratification. And here's the point. Unfortunately the biggest limitation of upper tract, these specimens are not adequate enough. And a CT imaging is not adequate enough to risk attribute, you know, muscle invasive versus non muscle invasive disease. And thereby, getting a feeling of the likelihood of macro metastasis and lymph node metastasis and so forth. So the upper tract is sort of classified in two groups. It's high-risk and low-risk, and this is a moving target. It's a dynamic target. And you mentioned the early papers, with Jay Ramond and so on, we try to come up with an idea, while you were in the lab, right? And, Jay was with us at UT Southwestern and trying to come up with an idea how we can categorize a tumor that is so safe to treat with kidney sparing, that we wouldn't lose any because the standard of care was radical nephrectomy for every patient. And we know all the series that have, we've seen 20 to 25% of patients got unnecessarily radical intervention. We get treatments, not only surgical detriments or a side effect, but also kidney function detriments long-term. So, which patients can we safely spare the kidney, without an increased risk of metastasis and progression, but accepting a high risk of reintervention without metastasis? This was sort of the concept. So the criteria that are currently set forth are very restrictive. Every case can have an indication to be a little bit more, pushing their agenda. So what do we call it? A low risk tumor that is sort of, we believe safe for kidney spending approach is a unifocal disease.
But we all know if you have three little TA tumors next to each other, that's not what we mean. Unifocal we mean renal pelvis and ureter. Why? Because the likelihood, if you have a multi-focal disease at different locations, it's more likely to be a higher risk disease that is misclassified as low risk disease. Number two, the tumor size has to be in some sort of volume that is manageable endoscopically. With a modern instrument, with a whole retroflection everything, with access sheath and so on, we can get to all the locations and probably can achieve an adequate specimen. So it's two centimeters currently the cutoff, but we know that the two centimeters is not ideal, like three centimeter lesions that could be managed. It is one centimeter lesions that are difficult to manage. The cytology needs to be negative because a high-grade cytology is an indication for high risk disease. And, the biopsy specimen, at least I want to know the grade of the tumor. Right. The technique I was describing before with holmium excision is sort of the concept of unblock from the bladder unblock from the upper tract to get a good specimen, but it has to be low grade on a ureteroscopy. And on the CT, as you mentioned, no indication for invasiveness. If all those criteria are fulfilled, we feel safe to move with, what do we call a conservative? But conservative is the wrong word is a kidney sparing strategy. And the treatment, the diagnostic, as we mentioned before, the diagnostic step is also the therapeutic step. Now we can talk about it afterwards. Today, we strongly believe the patient needs a re ureteroscopy in some time from between four and eight weeks up to three months to make sure there's no residual tumor. So part of that is based on the low level of evidence, a retrospective series. Because there's residual tumor and misclassifications, that can happen based on specimen acquisition.
So a second intervention, and then the patient is safe for kidney sparing approach. In general, low grade tumors come as low grade tumors back. And this is the same thing in the bladder as in upper tract. You have a very low risk. I realized those criteria, you know, based on all retrospective data, poor quality, and then we set them forth to be safe. And now we are a little bit stuck because we want to push the agenda. What do you think?
[Dr. Aditya Bagrodia]
So first of all, I think endoscopic management of upper tract disease is a total labor of love. These are painful cases. They take, they can take two, three hours and I get it. I mean, we're all human. The desire to say, oh, this is not endoscopically manageable, they're going to need a nephrectomy, I think on everybody's mind. So I think we just need to acknowledge that and I think you're spot on, I mean, a. Estimating the size of a tumor endoscopically is a bit of a joke. Um, you know, two centimeter. I can hardly tell what a tumor is even now after doing a flexible cystoscopy, much less ureteroscopy. So I think you get a feel, is this a dangerous tumor? Is this a non-dangerous tumor? Okay. So if you feel like it's non dangerous and you know, there's of course patient co-morbidities et cetera, then, I will leave a stent in, and we can maybe talk about that here in a moment. Within six weeks, do a second look. And if there's anything even remotely suspicious, my threshold to do a third look is very, very low. I think there was some nice data from Temple and Dr. Bagley who recently passed that suggest that even at a third look, you're going to pick up almost 20% of tumors. So once I've kind of gone through those second, at least second look, maybe third look, then I'll essentially start alternating imaging.
And I think it's absolutely mandatory to have axial imaging to make sure you don't have any extra luminal growth. And then, uh, alternate that with ureteroscopies, which are again, you know, painful, these are anesthetics and older sicker patients oftentimes. So, maybe I'll just pause there to see what comments you have on that.
[Dr. Shahrokh Shariat]
I think you are absolutely right. We know from the lower tract tumors that, an experienced urologist, and many urologists gain that experience with time. Your visual recognition of the biological behavior of the tumor can be pretty accurate. Now you could be thinking its low risk, but it's even a high grade tumor that for you seems, does look like high-grade, maybe even manageable with the strategy if we had adequate adjuvat therapeutics in upper tract. But everything is put into the complexity of the patient's general health, and risks and life expectation and everything. And so I think, absolutely with everything you said, I fully agree. Today I believe based on not level one, not level two, low level of evidence, but a lot of experience. And I think if we're going to go the kidney sparing route one has to be safe and recognize that intracavitary recurrence is going to happen at a higher frequency. It's okay. You discussed it with the patient. Is that he's okay with that? Psychologically, a lot of interventions, very close follow up, a lot of imaging, a lot of ureteroscopies. The only thing I do a little bit differently, and Bagley, as you mentioned, has been, one of the godfathers of this specialty and you and I have learned from Ilya Seltzer, bringing his thoughts. You remember?
[Dr. Aditya Bagrodia]
Sure.
[Dr. Shahrokh Shariat]
He has taught me a lot of little tricks, what to do, play the stand, maybe dripping the chemotherapy and so on. So today I'm not really sure which of those work; we can discuss that, but I would leave a double J and come back and schedule in like six to, we try to find out when is the best time. So, in a study we did on this eight weeks seems to be an adequate time, but it's like a six, eight or 10 weeks, whoever cares. But, at least a second look, and as you said, it's a lot of small work. It's like, you know, stone therapy, you cannot leave fragments behind, right? This is you need to get rid of everything, destroy them. You need a, if you have a low grade tumor and you think it's low grade, you need not to obtain always a new specimen. You need to just destroy the other specimens, full grade them with your laser.
The one thing I do differently now, and I think this is very difficult to make possible in the United States because of the regulations and reimbursement scheme is, I give a single dose of chemotherapy after ureteroscopy to decrease the bladder cancer recurrence rate. There is evidence even with ureteroscopic management. This has been shown to decrease your bladder cancer recurrence rate. We give it after endoscopic management as well.
[Dr. Aditya Bagrodia]
Yeah, absolutely. So clinically I know that's what I do. That's what I've certainly done by Vitaly and company in Dallas. And it may not be a revolutionary game changer, but I'm actually working with our current SUO fellow to design a clinical trial for a postoperative installation after any endoscopic trip. And I mean, the trial gets a little bit sticky, as you can imagine, you know, whether they're gonna go on to subsequent receive new agent chemotherapy and if for you, and then post-operative instillation or whether this is endoscopically managed. But, I think stuff that we can ultimately work through. But I mean, clinical practice wise, I feel like it's, again, older sicker patients and if you're taking it back for TURs and those are another anesthetic it's, it's not trivial. So that installation though, just to be clear is mostly to prevent bladder recurrences, not necessarily hoping for any retro grade trips to the pelvis and prevention of seeding. Is that fair?
[Dr. Shahrokh Shariat]
Right, I think in the past, there's been sufficient studies looking at insulation into the bladder will have a very low likelihood of, you know, retrograde reflux unless you resected the ureter creating unnecessary trauma, stricture risk and so on. And even in that case, you need 250 ccs, to have 50% of the patients having a reflux sufficient to reach the area of your surgery and thereby you're diluting the concentration with chemotherapy is essential. The concentration of the number of colony forming units in BCG is essential. So I do not think that it is possible even with a stent placement, even a high volume, high pressure voider. You're not going to get enough.
(7) Jelmyto Therapy for Upper Tract Urothelial Carcinoma
[Dr. Aditya Bagrodia]
Yeah. I mean, I think the data, whether you use dual lumen catheters and do like an installation or percutaneous nephrostomy tube, are again, individualized case-by-case recommendations. And obviously there's going to be indication, solitary kidneys, et cetera, where you're really trying to do everything humanly possible, recognizing there's no data, but you did touch on, you know, Jelmyto, which is an FDA approved option now for a low grade upper tract cancer. What are your thoughts and opinions?
[Dr. Shahrokh Shariat]
I have to tell you that I'm currently working with them to design a European study. So I'm highly biased and I've not done any, I'm not on any activities yet with them we’re just in a first stage, but we have a trial, uh, just before I forget, we are also designing a trial for, everybody and like everybody after ureteroscopy, and the trial is so hard to design because your groups and your power, your need is like mind-boggling, but we should talk about that. Jelmyto, I think I've used it. I used it a patient in single cases, where they were collecting data for the FDA, we've used it in several patients. We had, good results. Just, observation of single cases, the data from the clinical trial Olympus trial that has been reported is certainly, on some ways promising someways a little bit, the stricture rates and other downsides that are a little bit worrisome. I think the concept of slow release and a gel that could have that effect could be is, is a brilliant concept. Will it work for the upper tract? I think we need further data, but certainly this could be an additional tool in our armamentarium for those cases that you mentioned that we really have to go all the way and you have to with the patient, see how much interventions do they need to go.
Another point I want to say. I do the follow-up ureteroscopies outpatient with not even rarely with sedation. With local anesthesia. We are in a very much torture setting, right. But it works single use ureteroscope, and I go up and make an intervention. And then as you say, I alternate the follow up. So I don't take him back to the OR for that. Then I do a sedation, like a colonoscopy, worst case scenario, but it is for this elderly population, a lot of follow up every three months, but they need the, every renal unit, a certain age, comorbid, metabolic syndrome and so on. So you're pushing the agenda in many of these patients. I think the Jelmyto, just to say an additional thing that I've used in the past, and that is based on Bagley's concept. I've used it to pass the perk let the BCG drippin in those patients that are high risk CIS type of guys, you know, not for adjuvant, but really for CIS, I think for CIS, I do not like to take the kidney out, if possible. So I've used that strategy by the move to the [inaudible] and let it drip in and they come every week. I do place a monitor. Make sure they don't have infection, no extravasation on a retrograde, no perforation. And let the BCG drop in over an hour as described previously and other strategies to have, in a hope that that carcinoma in situ is somehow treated. I know this is weak evidence.
[Dr. Aditya Bagrodia]
Yeah, but again, I think we're kind of doing the best we can and sometimes it's not just us driving the decision-making here, you know, an older infirm patients, not willing to go on dialysis, et cetera. We don't want to make that decision lightly. Clearly this has been such a rich discussion and we're not even to get to talk about the management of high risk cancer. But, it sounds like if I may, that, generally percutaneous resections, you know, outside of maybe extremely large tumors are something that you've largely moved away from. You know, again, recognizing that there may be specific scenarios, but, to maybe round out kidney sparing approaches a couple of comments on segmental ureterectomy, partial ureterectomy, surgical tips, tricks, indications, as we approach about 45 minutes.
(8) Partial Ureterectomy for Upper Tract Urothelial Carcinoma
[Dr. Shahrokh Shariat]
Yeah, I think it's a long range of options we have. So as I'm getting kind of older, I'm less risk averse in what I'm trying for the patients, you know, outside of clinical trials. But it's certainly the distal ureter is a fantastic option, even in, in invasive tumors, to get adequate lymphadenectomy plus if, if you think it's invasive, if you're not sure, but they'd get a distal ureterectomy, reimplant [inaudible] flap, whichever you want. So you can reach long ureters, I've had patients with the complete ureter involved. I've done bar flaps up to the pelvis, if it's a large bladder and so we've, we all have done, those crazy indications, rare indications but, in general, segmental ureterectomy, except distal ureterectomy, is a rare indication, but I've done it in tumors where I thought it's, I've taken just a tumor out. And I have just reanastomosed. They've been successful so far, I have to say, but it’s a matter of time until you have some form of problems that arise: strictures, poor blood supply to the mid-ureter or to the proximal ureter as well, problems that could arise. And number two, you have to be conscious of that and discuss that with the patient, but also, I think the other strategy, that certainly makes sense is to be really very aggressive with your endoscopic management of those that you don't think are mid ureter. But I can really count on my hand, segmented ureterectomies, mid ureter and proximal ureter.
[Dr. Aditya Bagrodia]
Yeah, totally agree. I mean, they're rare, it's an older sicker patient and the things that I typically try to teach the residents and fellows are make sure you clear the remainder of the upper tract. You know, they need to get a comprehensive ureteroscopy at some point. And then, I think it can be tricky, say it's a distal ureterectomy, I like to clip above and ideally below. But if it really extends down to the bladder cuff, when you're doing the bladder cuff, I think technically to really get through the perivesical fat, get through the detrusor, have your mucosa out, isolate that. So you're not having tumor spilled and where you're literally holding your you've got your stay stitch in so that you're not having any tumor spill into the peritoneum for instance, or putting yourself at a higher risk of a low local bladder recurrence, any kind of surgical tricks on that Shahrokh?
[Dr. Shahrokh Shariat]
Yes, you know, we looked, and you guys have also from UT Southwestern, have published papers on this and we have published a bunch of papers in it in multiple groups. You know, we also have external validation courts. We have looked at that have tried to look at what is the best management of the distal ureter, doing radical nephroureterectomy, but could be also applied to just distal ureterectomy. What consistent data shows us but I'm not really sure what to make out of it is, number one is you need to remove the whole distal ureter with adequate bladder call. Okay. We kind of all agree with that. That's common sense, but interestingly older, early strategies that we've used to bypass that laparoscopically doing something stapling across, have been inadequate and as complicating, managing and resecting it I've been kind of in inadequate to consistently achieve a bladder cuff that has sufficient acquisition to ensure that we have a lower risk of intravesical recurrence, which is the end point in many of these tumors.The metastasis in survival, but the intravesical recurrence rate and, you know, in the high-grade tumors also obviously the audit to endpoints. I like to see the superior vesical artery. I like to see the ureter. I like to dissect this all out. If I don't see that I'm not dissected far enough and you're always in for a major surprise. How far are you? You feel like you are at the end and you’re still not there. So for me, I've, even robotically. It sounds kind of crazy and overkill, and this is what we've found in all our data. But I think this has to do with selection bias. I open the bladder and I like to look at it from the bladder. So, you know, retro flexing under your ureter, making sure all out. And I don't like that extravesicular approach, for myself to make sure, but I agree that it, in any concept, it cannot be inferior if you remove the whole specimen, putting the stay suture, as you said. And so on, the seeding is always the problem. So you want to ensure that you don't have seeding and one strategy that at UT Southwestern, you and I have learned, and I like a lot, but there's no evidence for that is giving chemotherapy during the surgery. So you start with giving the chemotherapy, you let it in the bladder, you put the three-way catheter, you wash up until you get to that part. It's already out of the system. You may lower them, but you have to make sure you don't have a bladder cancer. Even if you don't do that, you have to make sure you don't have an active bladder cancer. The one thing you also want to also make sure you don't by sewing it together, you don't specifically robotically. I've seen it a few times happen. Don't sew other ureter, you have to have a visualization of the other ureter. Right? So closing that up and making sure that you have a good closure, because that will also determine when you're going to give the postoperative single shot chemotherapy dose. I love the strategy you mentioned, clipping the ureter specifically, radical nephroureterectomy, and immediately clip below the tumor and to decrease it. And I don't do it with distal cuffs because. I don't think it's going to have pressure going up, but probably makes sense. But clipping above and below the tumor certainly makes sense.
[Dr. Aditya Bagrodia]
Yeah, no, these are all kind of spot on. And I certainly asked the anesthesiologist, as soon as I close the bladder, can you please mark the urine output because I just want to make sure I haven't bagged the other one. I think these are all things where if you stay healthily paranoid, you're going to, avoid some potentially catastrophic situations.
[Dr. Shahrokh Shariat]
It's always surprising me. The things you can see is I've never, you know, I had one teacher that said, I've never seen this before. Everything can happen. And I like also to really think what's going to happen afterwards. So obviously, a guy that gets distal ureterectomy, I love to do a sort of a good a wide, you know, thing. So I can manage that upper tract easily with my followup ureteroscopy if I need it, imaging as well.
[Dr. Aditya Bagrodia]
Yeah. And I mean, if you have it nice and wide, oftentimes after their surveillance, cystoscopies you can just drive your cystoscope right up into the kidney and it makes it pretty manageable. Well, Shahrokh, I think, this has just been a wealth of information for me, kind of running through, you know, picking your brain on diagnosis and management of kidney sparing approaches. And, maybe, you know, as we kind of wrap up here, any just kind of thoughts that you'd like to share with the listenership on, your mentality, philosophy, and approach to this disease.
[Dr. Shahrokh Shariat]
First of all, thank you so much. And it's kind of all, you know, talking to you is talking to myself almost because we share the same school, would UT Southwestern Memorial Sloan Kettering, strong influence in UTSW of MD Anderson, thought about this, you know, philosophy about these diseases. Urothelial carcinoma specifically. So I think the one thing that I really want to push the agenda is the two points we talked about. First of all, I think it's a moving target too. We're learning a lot about upper tract, I think with the wealth of genetic data that has come with you majorly involved with a group with Jonathan Coleman, uh, David Solit and so on. I think we've learned a lot. We're seeing specifically in this disease, we're going to have the genetic and epigenetic signatures will help us refine our strategies better in the future because our pathologic specimens are just inadequate. Biomarkers and so on will be much more important in this disease than in other diseases specifically, given the heterogeneity of this disease and extended graft models and so on to identify therapy. I think it is very important to understand that we really have to get away from monotherapy. It is just radical nephroureterectomy for everybody. It’s easy. It's good reimbursement. It's just a destructive surgery. So you, you don't have to reconstruction. The pain is not that much. Patient's not going to come with erectile dysfunction or whatever. So everybody loves it. It's laparoscopically an easy intervention to do. And also the distal cuff open or robotically can be done easily, like done whatever you want with a new robotic systems. You can do both in one axis. but that is not the end point.
The end point is to do what the patient needs right at that moment. So I think avoiding over-treatment whenever you come with good ureteroscopy diagnosis and imaging diagnosis, we didn't talk about FDG PET, which could have some benefit in staging a little bit, but probably not as much as we think. Newer, hopefully, tracers will be better. It will never be the PSMA PET as we have seen in prostate cancer. But number two also, we have not really discussed it, but we've touched on it. I think for those patients that need radical therapy, multimodal therapy is so important because the risk of macro assessment is very important and really understanding which patients to choose for neoadjuvant or adjuvant therapy is essential specifically in this space where, you know, nivolumab has been, is a player in an adjuvant setting. The Powell trial, despite hitting DFS, but not overall survival. What are you going to make out of that? But the same thing happens with the nivolumab. And I think these are key issues. And I think it's not the tool you use, but the philosophy user will determine, and with your patient find the strategy that fits him or her with that tumor at that moment, based on that biology at the time. So kind of fulfilling the promise of personalized precision medicine is even more important in upper tract than in other disease, because they are not strict schemes. And the heterogeneity of the disease is odd. And each time you intervene with a tumor, you're changing the natural history, similar to bladder cancer, right? Seeding happens. This happens, that happens. So you’re changing the biology, you're changing the clinical behavior. So overtreatment is what we have to get away from.
[Dr. Aditya Bagrodia]
Yeah, I think that's, that's spot on Shahrokh and you know, it just maybe reflecting a bit from the 2009 cancer paper outcomes of radical nephroureterectomy to where we are now with the advances in sequencing the advances in understanding, you know, the biology between Lynch syndrome and myristoleic acid, prospective level, one data, like the Powell trial, it's really been an explosion. And I think it's fair to say. Exciting this international interest in upper tract, you know, squarely falls in your domain in a large place. So, thanks for your contributions for upper tract and for your thoughts today, it's really been a pleasure and I look forward to having you again soon.
[Dr. Shahrokh Shariat]
Thank you so much Aditya. Thank you so much. I know it's very early in LA, late in Vienna and, thank you for the love, and for the podcast is, you know, enriching for all of us. And I think, sharing the little I've learned over the years, but the last thing I want to say. All of this is only possible, and I'm not going to say it's because of patients, you know, all these sentences, everybody says, it's because people have to come together to address a rare tumor. And urology is full of rare tumors, penis cancer, urothelial, urethral cancer. We have a lot of rare tumors, even testicular cancer. If we think about it, it's not that common a disease. So putting all these brilliant minds together, getting the researchers active, the clinicians, young dynamic minds, pushing the agenda, learning from other specialties, learning from the endoscopies, from the stone experts. And so it has really been, and technological access has revolutionized our view of the disease, but has not changed the biology of the disease. Just helped us to address the biology better.
[Dr. Aditya Bagrodia]
Alright, perfect Shahrokh. I know you've got plenty going on, man. It's really nice to spend some time talking with you, and congrats on the baby and best of luck with the next six months.
[Dr. Shahrokh Shariat]
Haha late bloomer, late bloomer here.
[Dr. Aditya Bagrodia]
Fantastic. Well, thanks Shahrokh, really really nice to see you.
Podcast Contributors
Dr. Shahrokh Shariat
Prof. Dr. Shariat heads the University Clinic for Urology at the Vienna General Hospital in Austria.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2022, March 23). Ep. 35 – Diagnosis and Management of Upper Tract Urothelial Carcinoma [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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