a. Insert Scope

b. Advance Through Urethra to Bladder

c. Inspect Bladder and Locate Ureteral Orifices

1. Cystoscopy

a. Right Side

b. Left Side

2. Placement of Ureteral Stents

3. Inspect Bladder

4. Secure Stents in Foley Catheter

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.

<h4>CHAPTER 1</h4>

<p>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.</p>

<p>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.</p>

<p>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 no
elevation of the hemitrigone, there's no abnormal masses.</p>

<h4>CHAPTER 2</h4>

<p>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.
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 or
if we meet resistance, we stop. So - that's perfect.
So that's his right stent, now.
It 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 ureter is heavily involved with the tumor.
So we back up and we look along that ridge again.</p>

<p>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 ureteral orifice.
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 good position.</p>

<h4>CHAPTER 3</h4>

<p>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
unusual 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 unusual
indentation, extrinsic pressure, or masses
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
surgical needs - urologic surgery needs - later.</p>

<h4>CHAPTER 4</h4>

<p>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 about
2 cm into the clear.
Otherwise somebody up in the floor
will 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.</p>


Watch this full-length, narrated video of a preoperative cystoscopy and ureteral stents placement performed preoperatively by Dr. Francis McGovern for a patient undergoing HIPEC surgery.

Massachusetts General Hospital