Comprehensive Urology

Diseases and Conditions

Procedures

Imaging Services

The daVinci System

Cystoscopy and Stent Placement Retrograde Pyelogram

Definition

Cyst = pertaining to the urinary bladder

Oscopy = procedure done through a scope as opposed to an incision

Stent = thin plastic tube that can be placed in the ureter

Retrograde = backward to the normal direction of flow

Pyelogram = injection of dye into the kidney and taking an x-ray

The ureter is a tube that connects each kidney with your urinary bladder. It is the most common site in which a kidney stone gets caught and consequently causes pain. There are other reasons that a ureter may become blocked. There could be narrowing scar tissue inside the ureter (termed a stricture). There could be compression from outside the ureter due to a tumor or inflammatory response somewhere in the abdominal cavity or pelvis. There can be congenital (something you are born with) defects in the ureter.

When there is an obstruction in the ureter, it is sometimes necessary to place a tube (stent) inside. Sometimes, a special scope procedure (ureteroscopy) may be performed to diagnose or treat the problem right away. Sometimes, just a stent is placed to unblock the kidney. When this is done, a more definitive procedure may be done in the future.Sometimes, a stent can be removed at a later date without any further treatments. This stent is not visible on the outside of the body as one end is in the kidney, and the other in the bladder. Sometimes, a thin string is attached to the end of the stent in the bladder, and this string is left hanging out of the urethra. The stent can then be removed by pulling on the string. In the absence of the string, the stent can be removed with a scope procedure in the office.

The ureter or the inside of the kidney can sometimes be a source of hematuria (blood in the urine). There are different ways to evaluate a patient for hematuria. Sometimes, special x-rays (using injection of dye into a vein) can be used to examine the inner kidney and ureters.

Sometimes, a retrograde pyelogram is performed. This is when the dye is injected directly into the ureter (instead of into a vein) during a cystoscopy procedure. Your surgeon will explain why this procedure is being done instead of an x-ray with intravenous injection. Sometimes, a retrograde pyelogram is done prior to placing a stent to help demonstrate the anatomy of the ureter or even help diagnose the cause of an obstruction.

Preparation

There is no particular preparation for stent placement or for retrograde pyelogram. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time.

Sometimes, a stent placement or retrograde pyelogram can be done in the office without any sedation or with minor sedation. If this is the case, we recommend that you have not eaten for 2-3 hours prior to the procedure.

With regard to your medications, your anesthesiologist will have discussed (in a prior consultation if your procedure is being done in the hospital) which ones you should take the morning of your surgery. Any pill taken will be done so with only a small sip of water. If you have not been informed or have forgotten, please let us know.

Procedure

To review the basics of what we discussed in the office: The actual procedure can take anywhere from 15 minutes to an hour depending on the particulars of the case and the individual's anatomy. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters called stirrups). The scope is inserted into the urethra and into the bladder. The bladder is examined for any abnormalities.

Stent Placement: The ureteral orifice (hole where the ureter enters the bladder) on the side of concern is identified. A wire is placed into the hole and guided up the ureter to the inside of the kidney. A stent is then placed over the wire and advanced into the kidney. Once satisfied with the position, we remove the wire and the stent stays in the ureter. Each side of the stent forms a curl that helps it to remain in position. We may use x-ray guidance or ultrasound to help guide the placement. Sometimes, neither x-ray nor ultrasound are necessary.

Retrograde Pyelogram: The ureteral orifice (hole where the ureter enters the bladder) on the side of concern is identified. A small catheter is placed in the hole. X-ray dye is then injected into the catheter so that it flows up the ureter and into the inner aspect of the kidney. During and after the injection, we look at x-rays so that we can evaluate the anatomy of the ureter and inner kidney.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged. If done in the office, you may be observed for a short time before being allowed to leave. You may have some discomfort while urinating. This is from the cystoscopy. Although the stent is soft plastic, any degree of sensation from its presence is possible. Some patients have no feeling, while on the other extreme, some have very bothersome symptoms. The symptoms can be any one or a combination of back or groin discomfort (like still having a stone), urinary frequency, urgency or burning.

The symptoms may last only one day, or persist for the duration of the presence of the stent. Most patients, however, have very mild symptoms thatare tolerable.

After the procedure, it is rare to have blood in the urine. A small amount of blood staining is possible for a few days, however. When there is a sharp stone in the ureter or in men with large prostates, blood in the urine is seen more often.

Expectations of Outcome

It is not always possible to advance the wire or the stent into the kidney. The blockage in the ureter (stone or stricture) may not be passable. Sometimes the entrance to the ureter in the bladder (ureteral orifice) cannot be catheterized. This would prevent either procedure.

Sometimes in a male, a very large prostate can obscure the passage of a wire or a catheter into the ureter.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Urinary Tract Infection or Urosepsis (Bloodstream Infection): Although we may give you antibiotics, it is still possiblefor you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. We also see infectionsmore commonly in patients who already have a stent in place prior to this procedure.

*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.

  • Blood Clots in the Urine: As mentioned, bleeding is rarely significant from either of these procedures. If the bleeding is more severe, it can cause clots that can block the urine flow. A catheter may need to be inserted to flush out the clots.
  • Urinary Retention: Even in the absence of bleeding, the prostate in males can become swollen from the scopes pressing against it or less commonly secondary to infection. In this instance, a catheter would be placed and your doctor would discuss the next step. Patients at greater risk are those who already have difficulty urinating before the procedure due to BPH (benign prostatic hyperplasia).
  • Ureteral Injury: Despite precautionary measures, the ureter may be injured from the wire, the stent, or the catheter. If a stent can be placed, that is all that is necessary in the event of ureteral injury. The injury usually heals on its own. If the stent cannot be placed, the choices are observation or placement of another type of drainage. A tube may need to be placed into your kidney through a small hole in your back. Sometimes, we will ask doctors called interventional radiologists, to do this procedure. A complete ureteral avulsion (separation of the ureter from the bladder or kidney) is a very rare occurrence and requires open surgery through an incision to repair.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy orcompleteness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

Delta Medix, P.C.