Cytoreductive debulking surgeries can be complicated by difficulty identifying the course of the ureters in the retroperitoneum due to exacerbation by any anatomical distortion from tumor burden or history of previous intra-abdominal operations. Inadvertent direct injury to or devascularization of the ureters or the rest of the lower urinary system during the course of these procedures is a serious concern and can result in increased morbidity for the patient. In order to reduce these risks, urologists often prophylactically place ureteral stents in patients preoperatively in order to aid surgical oncologists in readily identifying the course of the ureters during surgery. Here we present the prophylactic ureteral stenting of a patient undergoing cytoreduction and hyperthermic intraperitoneal chemotherapy for extensive appendiceal adenocarcinoma metastasis. We outline the proper cystoscopic technique, identification of the ureteral orifices, stent placement, bladder inspection, and how to secure the stents with the Foley catheter. The stents were placed without incident and without encountering any resistance, suggesting the ureters were not heavily involved with the tumor. Inspection of the bladder revealed no unusual indentation, extrinsic pressure, masses, or other pathology.
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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. And so we're going to lift up - it's like climbing a hill. By climbing a hill - and then we're in the bladder.
Now, to find the uretal 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 uretal orifice. Once the orifice is in clear view - and we've noticed that there's no - elevation of the hemitrigone, there's no abnormal- abnormal masses.
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 guidewire because 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 will find its way around any sort of curvature. So now we're going to advance the stent - that's you. Yup. 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…
Good. Okay, let's see. Okay, so that should be up - to the level of the renal pelvis or if we meet resistance, we stop. So - that's perfect. So that's his right stent - now should be well up that ureter - on the right side, and there was no unusual resistance, which is always a good sign. If we meet resistance it could be that the - the 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 stent over that guidewire - always keeping an eye on the screen. Okay? That's beautiful. So he's intubated the left uretal orifice. The - The stent is passing freely. We try to get all information we can to give to our surgical colleagues. So if there was resistance, or if we met a point where the stent wouldn't pass, we would measure how far up above the bladder that is. So both stents now are in - in good position.
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 no un- unusual extrinsic mass effect. Susan, can we turn the light up on that? And then we'll do it a - 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 unusual indentation, extrinsic pressure, or masses in- infiltrating 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 any - any surgical needs - urologic surgery needs - later.
Okay, so this is how we - what we do with the stents during the procedure. We tunnel them into the - into a Foley catheter. There's the other one. Good. There are 2 shops right here.1 and 2. And Jim likes these - to have a suture on them. So we'll put a silk suture - so we bring this out far enough…
Usually I pull them so that they've got about 2 cm into the clear. Otherwise somebody up in the floor will - will compress it into the drainage bag. Okay? Good. And then so, yup, you can tie some on that. Tie 1 about here. Very good. Nice job. Thank you. You're welcome.