Cystoscopy and Placement of Ureteral Stents: Preoperative for HIPEC Surgery
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The combination of surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has considerably transformed the treatment approach for patients with malignant tumors with peritoneal involvement, notably enhancing the prognosis for advanced abdominal malignancies. The identification of the ureters in the retroperitoneum can be challenging due to anatomical distortions caused by the tumor or prior intra-abdominal surgery. Iatrogenic ureteral injury (IUI) during any pelvic or abdominal surgery poses a significant problem to patient morbidity.1 This can be exacerbated by delayed diagnosis due to the non-specific nature of its clinical presentation. The prevalence of ureteral injuries in the context of advanced oncological abdominal and pelvic surgery is 6%.2 Furthermore, weight loss and malnutrition, which are highly prevalent among cancer patients, are known risk factors for IUI.3 In order to reduce this risk, urologists often perform prophylactic ureteral stenting (PUS) preoperatively, which helps in the identification of the course of the ureters during surgery. The use of PUS in patients who are receiving CRS-HIPEC treatment could be beneficial, especially for those with a pre-existing extensive pelvic disease. However, the placement of PUS is not devoid of possible health complications. Therefore, it should be thoughtfully considered for patients where the advantages are greater than the potential risks.4
This video provides a comprehensive overview of the PUS and cystoscopy performed on a patient with advanced metastases of appendiceal cancer who is scheduled for CRS-HIPEC. The video focuses on urethral instrumentation, identification of ureteral orifices, stent placement, and subsequent bladder inspection. The patient's preoperative evaluation had revealed no evidence of ureteral involvement with the tumor. The cystoscopic technique employed in this case allowed the surgeons to visualize the bulbar urethra, sphincter, and prostatic urethra, illustrating the step-by-step process of advancing into the bladder. Next, the vesical trigone is identified, aiding in the visualization of the ureteral orifices. The careful placement of stents into both ureters is demonstrated. No resistance was encountered in the process of stent placement, suggesting no involvement of the ureters with the tumor. A thorough bladder inspection revealed no unusual findings such as abnormal lesions, masses, or other pathology. The stents were secured with silk sutures to prevent inadvertent dislodgement.
For carefully selected patients, PUS is a highly valuable and safe tool for the prevention of IUIs during high-risk procedures like CRS-HIPEC. It’s use has been postulated to decrease the likelihood of unintentional ureteric injuries and postoperative ureteral complications without increasing the risk of urinary tract-related complications.4, 5
Citations
- Locke JA, Neu S, Herschorn S. Morbidity and predictors of delayed recognition of iatrogenic ureteric injuries. Can Urol Assoc J. 2021;16(1). doi:10.5489/CUAJ.7271.
- Fugazzola P, Coccolini F, Tomasoni M, et al. Routine prophylactic ureteral stenting before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: safety and usefulness from a single-center experience. Turk J Urol. 2019;45(5). doi:10.5152/tud.2019.19025.
- Halabi WJ, Jafari MD, Nguyen VQ, et al. Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. Dis Colon Rectum. 2014;57(2). doi:10.1097/DCR.0000000000000033.
- Hanna DN, Hermina A, Bradley E, et al. Safety and clinical value of prophylactic ureteral stenting before cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am Surg. 2023 May;89(5):1436-1441. doi:10.1177/00031348211058622.
- Abu-Zaid A, Abou Al-Shaar H, Azzam A, et al. Routine ureteric stenting before cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in managing peritoneal carcinomatosis from gynecologic malignancies: a single-center experience. Ir J Med Sci. 2017;186(2). doi:10.1007/s11845-016-1452-4.
Cite this article
McGovern F. Cystoscopy and placement of ureteral stents: preoperative for HIPEC surgery. J Med Insight. 2024;2024(218.2). doi:10.24296/jomi/218.2.
Procedure Outline
Table of Contents
- Insert Scope
- Advance Through Urethra to Bladder
- Inspect Bladder and Locate Ureteral Orifices
- Right Side
- Left Side
Transcription
CHAPTER 1
So we have the scope here set up with the stents.If you can see those, that's good.And let's have doctor Dr. An -he will do the scope here.So -what you're going to do is hold the penis with your left hand.See - this - you hold that with your left,and then you'll put the scope in -to the meatus.And then you're going to watch right there at the screen,and yet the key is to -the key is to pull the - this penis straight up.Okay.And that's it, and now we're going to put the fluid on,which is going to give you an even better view.
Okay, so this is the - the bulbar urethra,and then we're going to go by the sphincter, which is right here.And then once we go above the sphincter,this will be - this will be the prostatic urethra.And so we're going to lift up - it's like climbing a hill.Like climbing a hill - and then we're in the bladder.
Now, to find the ureteral office -you see this ridge here? This is called the trigonal ridge.So first what he's going to do is walk along the ridge,and there he finds the ureteral orifice.Once the orifice is in clear view -and we've noticed that there's noelevation of the hemitrigone, there's no abnormal masses.
CHAPTER 2
And so we're going to put this right there, we're going to leave it,and then we're going to see if we can intubate that with a guidewirebecause many of these cases, the patients have had previous surgery.And so yeah, the guidewire's in the ureter right now.We push that up because the guidewire has a floppy tip and willfind its way around any sort of curvature. So now we're going toadvance the stent - that's you.Yep. And we'll advance that stent up.And we usually try to put it to the level of the renal pelvis,so that the surgical team...Good. All the way.And...Yep.Good. Okay, let's see.Okay, so that should be up to the level of the renal pelvis orif we meet resistance, we stop. So - that's perfect.So that's his right stent, now.It should be well up that ureteron the right side, and there was no unusual resistance,which is always a good sign. If we meet resistance it could be thatthe ureter is heavily involved with the tumor.So we back up and we look along that ridge again.
Walk the ridge, and the ridge will take you to the orifice.There's the other orifice right there,and we'll repeat the process on this side.We'll put the stent out.We'll put the guidewire...I'm going to pull the stent back a little bit.Here we're going to bank it like this.Good. And then we're going to advance this stentover that guidewire.Always keeping an eye on the screen.Okay?That's beautiful. So he's intubated the left ureteral orifice.The stent is passing freely.We try to get all information we canto give to our surgical colleagues.So if there was resistance, or if we met a point where thestent wouldn't pass, we would measure how far upabove the bladder that is.So both stents now are in good position.
CHAPTER 3
And the next step is, again, when we come into the -this is the prostatic urethra here, bladder neck.When we enter the bladder, we notice that there's nounusual extrinsic mass effect.Susan, can we turn the light up on that?And then we'll do a tour of the bladder,first looking at the right wall,which looks very normal - we don't see any mucosal lesions.We're looking higher up.Higher up, you'll see the air bubble denotes the dome of the bladder.Air rises to that dome. And there's no extrinsic mass effect.The bladder walls are smooth throughout with some mild trabeculation,which is normal for this age group. But there's no unusualindentation, extrinsic pressure, or massesinfiltrating or invading the bladder.So, our job for this patient,for this segment of the procedure, is complete.And we'll be available if there's anysurgical needs - urologic surgery needs - later.
CHAPTER 4
Okay, so this is how we -what we do with the stents during the procedure.We tunnel them into a Foley catheter.There's the other one.Good. There are two sharps right here.One and two.And Jim likes these to have a suture on them.So we'll put a silk suture. So we bring these out far enough...There it is.Usually I pull them so that they've got about2 cm into the clear.Otherwise somebody up in the floorwill compress it into the drainage bag.Okay?Good. And then so, yep, you can tie some on that.Tie one about here.Very good. Nice job.Thank you.You're welcome.