Cystoscopy and Placement of Ureteral Stents: Preoperative for HIPEC Surgery

Case Overview

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