A 76-year-old female presents with a history of microhematuria and two positive cytologies for urothelial carcinoma obtained from bladder washings. Cystoscopy was negative for any obvious lesions in the bladder. She has no prior urologic history, denies any smoking history, and denies recurrent urinary tract infections (UTIs). A retrograde pyelogram (RPG) was performed on the right side as shown in figure 1. The left side RPG was unremarkable. Ureteroscopy was performed on the right side and three lesions were encountered as shown in figure 2.