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

CHAPTER 1

Let's do a quick time out for me. Yeah, let's do time out. He's here for a cystoscopy, right ureteroscopy, possible biopsy, possible laser of any right renal mass, possible ureteral stent insertion. And allergies? None. Good. Consents have been reviewed and signed. He got two grams of Ancef. Excellent. No blood loss is expected. No blood needed. Single operative field. Antibiotic, we discussed. DVT prophylaxis with SCDs. Normal thermo measures. Upper body Bair Huggers on. Intra-op use for critical meds discussed. Hopefully, nothing necessary. Radiographic here. Radiographic imaging is ready and here. No clipping. No clipping. Fire risk is minimal to moderate with a light source and we have an extinguisher in the hallway. Any other considerations? Very good. We may proceed.

CHAPTER 2

Okay, so as we start, we insert the cystoscope into the urethra. You see the penile or pendulous urethra. This is the bulbous urethra and we pass through the membranous urethra or the sphincter and into the prostate. This is prostate, it is slightly enlarged. All right. Primarily right lateral lobe hyperplasia, but no significant median lobe. Let's empty his bladder and then perform a complete cystoscopy. Do a quick spin. Make sure there are no tumors within the bladder. Needs to be deeper. He needs to be deeper. Okay, okay. 30 seconds. Okay. Thank you. Mucosa is normal. Mild glomerulations. No masses. No stones, no diverticuli. Looking at the anterior and the dome of the prostate, everything appears healthy. And the ureteral orifices, we visualize in their normal anatomic, orthotopic locations. Can we have a double lumen?

CHAPTER 3

Good. We'll find the right ureteral orifice. Fill up this bladder a bit, come back to the center and then move your way across. You have to look for the right ureteral orifice again. It's not gonna be that lateral, I don't think. I would definitely stop filling him now. It's gonna be right on that ridge, back up. It's gonna be right on this maybe. I think it's gonna be along, right there. Okay. Excellent. We'll pass a wire first. Excellent. One second, that's going up nicely. Good. We'll pass the double lumen catheter. A little further, that's good. We'll take a retrograde pyelogram. Looks relatively normal. Okay, go ahead and hub that. That way we can allow soft dilation of the ureter prior to passing our flexible ureteroscope.

CHAPTER 4

You ready for it? Yes. I'll take it from you. Cover it? Yes. Thank you. We'll pass a second wire. One wire will be our working wire for the flexible ureteroscope to pass over, and the second wire, will act as a safety wire in case we have any issues and need to place a stent. We're just gonna give this a couple moments to softly dilate. Perfect. Upper pole looks normal to me, which is good, that was the concerning area. Two wires up. Another 30 seconds of soft dilation. Give us our best chance for this flexible ureterocope to go up in an unstented ureter. Okay. Push, pull. Remove the double lumen catheter. We'll break down this camera. Remove this cystoscope, empty his bladder, and insert our flexible ureteroscope, gotcha. Excellent. I've got the wire. You can go ahead and pass. Go for it. Keep going. Go, go, go, go, go. Keep going. It's as high as we're gonna get it. Let's see if maybe we can just ride up. Hang on. There you go. I'll grab your check flow. Pretty tight there. It looked tight on the retrograde as well, so we may have to just place a stent, we'll see. I will help flush for you. Let's see. That looks pretty tight. No, take that out. Let's try and just go over one wire now. So take that all the way out. Okay, take the ureteroscope all the way out. Slipping out, taking a look down the ureter as we come out. No abnormalities there, okay. And now, let's try this again with only one wire. Got it. Here we go. Wire is still up. I have the wire. Good to go. That's the tight area. Close. Not gonna happen. Yep, not gonna happen. Okay, let's just pass a stent and come back. All right. Are we gonna place a stent? Yes. I'll need a six French multi-length stent please. Is that the same as the one that opened before? Correct, yes. Thank you. Alright, hang on to this real quick.

CHAPTER 5

Nice. Very nice. Okay. So over a wire, we will go back into the bladder with our cystoscope to safely pass an internal stent, which will softly dilate the ureter until his subsequent procedure in a couple weeks. Right ureter? Correct? Right ureter. Okay. Okay. Turn on some fluids so you can see, good. Okay. And we're passing the stent over a wire known as the Seldinger technique. Safely pass this stent in, coming at ya. Give you a pusher. There you go. One curl, two curl. So just between his lateral lobes, yeah. Excellent. Good curl up top. Good curl down below. Excellent, and this concludes our procedure. We will empty the bladder completely and remove all of our instruments.