Cystoscopy, Right Ureteroscopy, and Ureteral Stent Insertion with Aborted Biopsy and Potential Laser Ablation of a Right Renal Mass

Endourological procedures have revolutionized the diagnosis and treatment of upper urinary tract pathologies over the last years. Among these, cystoscopy combined with ureteroscopy has become a standard approach for diagnosing and treating various urological conditions, including upper urinary tract tumors, stones, and strictures.¹ The evolution of smaller-caliber flexible ureteroscopes, improved optical systems, and advanced accessories has significantly enhanced the diagnostic and therapeutic capabilities of these procedures.^2,3

The management of upper tract urothelial carcinomas and suspicious renal masses has particularly benefited from advances in endourological techniques. Early detection and treatment through ureteroscopic approaches have demonstrated safety and improved outcomes.^4,5 However, the success of these procedures heavily depends on obtaining adequate access to the upper urinary tract, which can be compromised by anatomical limitations.

The incorporation of laser technology in endourology has further expanded treatment options, particularly for the ablation of small tumors and the management of strictures. When combined with flexible ureteroscopy, laser treatment can provide precise and controlled tissue ablation with minimal collateral damage. However, successful ureteroscopic intervention depends on sufficient ureteral access, which may necessitate preliminary dilation in cases where ureters are too narrow.^6,7

This article describes a case of a 58-year-old male patient with a renal mass, which was incidentally discovered on an imaging of chest CT scan, without any signs and symptoms indicative for renal masses. The patient has no history of ureteroscopy before, and no prior history of urolithiasis. The multiphasic, contrast-enhanced abdominal CT scan shows 2.5-cm hyperattenuating enhancing mass in the upper pole of the right kidney. Transverse unenhanced CT image shows hyperattenuating mass with no evidence of fat. Transverse CT image shows enhancement of the mass from 60 HU to 116 HU. Thе chest CT scan showed no abnormalities.

This video describes a complex urological procedure that initially aimed to perform diagnostic and potentially therapeutic intervention but was modified due to anatomical constraints. The procedure demonstrates the importance of surgical adaptability and the role of staged approaches in urological surgery.

The procedure was initiated following standard surgical protocols, including a comprehensive timeout and administration of prophylactic antibiotics, specifically 2 grams of Cefazolin. Safety protocols were implemented to address potential fire risks from surgical lighting, while patient temperature was regulated using a forced-air warming system applied to the upper body.

The cystoscopic examination was initiated with the systematic visualization of the urethral anatomy. The 30-degree, 17 Fr rigid cystoscope with 2 working bridge channels was carefully advanced through the penile urethra, proceeding through the bulbous urethra, and subsequently traversing the membranous urethra before entering the prostatic urethra. During this initial phase, examination revealed a slightly enlarged prostate characterized by right lateral lobe hyperplasia, though notably without significant median lobe involvement, and a non-significant bladder trabeculation. A thorough evaluation of the bladder was performed, revealing normal mucosa with mild glomerulations. Significantly, no masses, stones, or diverticuli were identified during the comprehensive bladder examination. The ureteral orifices were visualized in their normal anatomic orthotopic locations, displaying a characteristic double-lumen appearance.

Following the successful completion of the cystoscopic examination, the procedure progressed to the more technically demanding phase of right ureteral orifice cannulation. A stiff hydrophilic guidewire (diameter 0.032’’) was initially introduced and successfully advanced, followed by the insertion of a  10 Fr double-lumen catheter. A retrograde pyelogram was performed, which demonstrated relatively normal upper tract anatomy. In preparation for the anticipated ureteroscopy, a second safety wire was placed to facilitate potential stent placement if required during the procedure.

Technical difficulties during ureteroscopy required a change in surgical strategy. Despite using a dual wire technique and soft dilation, scope advancement was prevented by significant ureteral narrowing. The second attempt utilized a single-wire technique, which provided better control but failed to overcome the anatomical limitations of the narrowed ureter.

Given the encountered anatomical limitations, the surgical plan was modified to include ureteral stent placement as a temporary solution. The cystoscope was reintroduced over the guidewire utilizing the Seldinger technique, enabling safe and precise placement of a 6 French multi-length stent. Proper positioning was confirmed through visualization of appropriate proximal curl formation in the renal pelvis and optimal distal curl positioning between the prostatic lateral lobes.

The modified procedure achieved several critical objectives despite the inability to complete the initially planned ureteroscopic evaluation. The comprehensive diagnostic cystoscopy provided valuable anatomical information, while the identification of the anatomical limitation prevented potential trauma to the ureter. The successful placement of the ureteral stent established a foundation for staged intervention, allowing for gradual ureteral dilation and improved access to subsequent therapeutic procedures.

Multiple important urological surgical concepts and techniques are effectively demonstrated in this video. For urological surgeons and trainees, the video shows the importance of a proper sequential approach to complex procedures while highlighting the necessity of maintaining surgical flexibility. The described approach emphasizes patient safety through appropriate modification of surgical plans when encountering anatomical challenges. This video serves as both a technical guide and an educational resource for urological surgery teams.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.