in contrast to bladder tumors ( bt ) , ureteral urothelial tumors ( uut ) are uncommon ; the bt : uut ratio is 33:1 . the incidence of uut is higher in areas affected by balkan endemic nephropathy ( ben ) , with low  grade lesions prevalent .
all urothelial tumors have a propensity for multicentric growth in space and time and a high rate of recurrence ; almost every second bt will reoccur .
patients with uut face a bt development risk of 2050% , while the risk is 10 times lower inversely .
however , it has been proved that the efficacy of conservative surgery is comparable to that of nu in patients from areas affected by ben .
endoscopic treatment is indicated for single , small ( < 1.5 cm ) low  grade tumors in older patients at risk from open radical surgery , a solitary kidney , or bilateral disease .
if there is a recurrence , it can be treated with an additional endoscopic procedure .
the lady was born in 1929 in a small village in south eastern serbia ; she has never smoked . in march 1994
a pathological examination revealed transitional cell cancer ( tcc ) stage ta , grade g1 . over the next 20 years the woman had 24 recurrent low 
grade bts and five ureteroscopic fulgurations for about 30 urothelial tumors in the left ureter ( figure 1 ) . the positions and size of the tumors in the urinary bladder and left ureter from march 1994  march 2012 .
the first ureteral tumor was seen during a routine cystoscopy , emerging from the left orifice .
the tumor was biopsied and fulgurated : pathological examination revealed ureteral tcc , minimal tagi .
all further recurrent ureteral tumors were tag1 ; they were discovered by urs after two and after five months and fulgurated immediately .
ten months after the appearance of the first ureteral tumor , intravenous urography ( ivu ) revealed the presence of multiple defects in the left ureter suggestive of tumors ( figure 2 ) .
intravenous urography presenting multiple tumors in the lower part of the left ureter ( april 2009 ) .
subsequently , urs confirmed the presence of at least five tumors in the upper ureter and at least 10 tumors in the lower ureter .
the tumors in the lower ureter were biopsied , while all other tumors were fulgurated without biopsy .
the next evidence of recurrence was in the left ureter after 10 months ( one tumor ) and after 20 months ( 10 tumors ) ( figure 3 ) .
the three  dimensional ( 3d ) reconstruction based on ct  urography showing at least 10 recurrent tumors in the left ureter ( february 2012 ) .
ten months later , three 35 mm large tumors had occurred in the bladder , around the left orifice .
today , the patient is 84 years old and shows no signs of the disease .
the author finds this case interesting for a number of reasons : primarily due to the long history of bladder tumors without progression .
furthermore , the history of the disease can be divided into two parts : in the first 10 years malignant transformation took place in various parts of the bladder ; in later years the left ureter was the source of malignant cells .
the appearance of multiple small bts around the left orifice was most probably the result of downstream seeding of malignant cells from the ureter .
in addition , the ureteral tumors were small and low grade , without progression , which is not typical .
fulguration , despite multiple recurrences and repeated procedures , the patient is quite well and disease  free .
intravesical bcg therapy was administered twice , in 1994 and 1998 ; the duration of the therapy was 36 months .
after 2001 , there was a recurrence  free interval , followed by a period of small low  grade intraurothelial neoplasias , so bcg therapy was not continued .
intraureteral bcg therapy is generally recommended after conservative treatment of uut , especially where carcinoma is present in situ 
  by percutaneous nephrostomy ( pcn ) , or through a ureteric stent .
however , the long  term results have not been confirmed . in this case , the patient did not receive intraureteral bcg : the tumors were low 
nevertheless , the fact that massive recurrence appeared nine months later is convincing evidence that topical bcg was actually indicated .
however , indications did not quite accord with eau guidelines ( unifocal tumor ) , rather the tumors were small , non  infiltrative and low grade .
in addition , the patient was elderly and came from an area affected by ben . given the lack of laser equipment , which is in all likelihood superior , urs with fulguration was performed . in the period 20012004 ,
the follow  up consisted of control cystoscopy and urine cytology every six months , with a three  month interval between cystoscopy and urine cytology .
, urs has been repeated every 35 months , in combination with 3d reconstruction  ct urography .
although it is recommended , especially in muscle  invasive disease , ureteral cytology has not been performed , due to frequent urs .
it is interesting that despite the patient having 24 bts and over 30 uuts this does not reflect the extent of the disease .
specifically , if tumor volume is calculated using the sphere formula , the total volume of all bts is around 60 ml , yet the total volume of all uuts is only 1.1 ml .
this fact also justifies the  ureter  sparing  procedure , despite the large number of tumors .
the only complications were three stenoses in the left ureter , which were mild and did not progress .
it can be successfully performed in a highly select group of elderly patients with multiple small superficial low  grade uut , especially if they originate from areas known for a low uut malignancy potential .
 ureteral urothelial tumors ( uut ) are uncommon ; their incidence is higher in areas affected by balkan endemic nephropathy ( ben ) , with low  grade lesions prevalent . in these patients , 
 the efficacy of conservative surgery is comparable to that of nephroureterectomy . 
 endoscopic treatment is indicated for single , small and low grade uut , in older patients with significant comorbidity.the case of an 84year  old lady from an area affected by ben is presented . over 20 years , the patient underwent five endoscopic interventions for multiple uut , and numerous endoscopic interventions for recurrent bladder tumors.among a highly select group of patients , endoscopic treatment of multiple small superficial low  
 grade ureteral tumors may prove successful . 
INTRODUCTION
CASE REPORT
DISCUSSION