A Unique Urine Isolating Drape Technique for On-Table Pyeloscopy to Exclude Suspected Upper Tract Urothelial Carcinoma During Radical Cystectomy

Abstract

Clinical History:

A 72-year-old man undergoes a transurethral resection of a 1.5 cm bladder tumor completely obliterating the left ureteral orifice (UO). A radical cystectomy was performed as the tumor was found to be a high-grade pT2 urothelial carcinoma. A computed-tomography intravenous pyelogram phase clearly demonstrated a filling defect in the left lower pole and renal calix; however, an magnetic resonance imaging postcontrast failed to detect the same filling defects, possibly secondary to inadequate filling as the obstruction progressed.

Physical Examination:

Physical examination was unremarkable and vital signs were within normal parameters.

Diagnosis:

The history raises high clinical suspicion for an upper tract urothelial carcinoma. At a multidisciplinary team meeting, some surgeons advocated for a radical nephroureterectomy, others a unique drape technique that facilitates on-table pyeloscopy.

Intervention:

To investigate the upper tract filling defect, retrograde pyeloscopy was not possible because of the obliterated left UO. Our novel technique is the first described to facilitate on-table pyeloscopy with an open ureter that diverts ureteral fluid into a pouch instead of the abdomen after radical cystectomy when upper tract access is not otherwise possible. The diversion of ureteral fluid from the abdominal cavity minimizes the catastrophic theoretical risk of tumor seeding ^{1 –5} that has been known to happen along percutaneous nephrostomy tracts. ⁶

Follow-up/Outcomes:

The filling defect was most likely caused by a fungal ball seen on pyeloscopy, and as there were no signs of malignancy observed this patient was saved from a potential nephroureterectomy.

No competing financial interests exist.

No funding was received for this article.

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Patient consent statement:

“I give full informed consent to the research team for this research project including recording of the operation for the purposes of research and publication of a video and any written materials.”

Runtime of video: 4 mins 56 secs