What is the operative sequence for a retrograde right‑kidney procedure via cystoscopy in an adult patient?

Operative Sequence for Retrograde Right Kidney Procedure via Cystoscopy

Pre-Procedure Preparation

Before any instrumentation, perform a complete cystoscopic examination of the urethra and bladder, documenting any mucosal abnormalities, masses, or anatomical variants. 1

• If urethral injury is suspected, obtain a retrograde urethrogram before bladder catheterization to avoid worsening any disruption 1
• Monitor the patient for contrast reactions including hypotension, hypoxia, or allergic manifestations throughout the procedure 1

Step-by-Step Operative Sequence

1. Cystoscope Insertion and Bladder Inspection

• Insert the cystoscope (rigid or flexible) through the urethra under appropriate anesthesia
• Systematically examine the entire bladder mucosa, noting tumor size, location, configuration, number, and any abnormalities 1
• Identify both ureteric orifices to confirm normal anatomy

2. Right Ureteric Orifice Cannulation

• Position the cystoscope to visualize the right ureteric orifice
• Insert a 0.9 mm hydrophilic guidewire through the working channel and advance it into the right ureteric orifice 2
• Under fluoroscopic guidance, advance the guidewire up the ureter and into the right renal pelvis 2

3. Catheter Placement for Contrast Injection

• Thread a 4F or 5F general-purpose catheter (or whistle-tip ureteral catheter) over the guidewire 3, 2
• Advance the catheter to the desired level in the collecting system under fluoroscopic visualization
• Remove the guidewire while maintaining catheter position

4. Retrograde Pyelogram Acquisition

• Inject dilute water-soluble contrast medium through the catheter under fluoroscopic monitoring 1
• Obtain multiple fluoroscopic images to visualize the right renal pelvis, calyces, and ureter
• Document any filling defects, strictures, stones, or extravasation

5. Stent Placement (If Indicated)

• If ureteral stenting is required, exchange the hydrophilic guidewire for an ultra-stiff guidewire 2
• Pass a double-J ureteral stent over the wire directly into position 2
• Confirm proper positioning with the proximal curl in the renal pelvis and distal curl in the bladder under fluoroscopy
• Remove the guidewire while maintaining stent position

6. Procedure Completion

• Remove all instruments under direct visualization
• Ensure both stent curls are properly positioned if a stent was placed
• Document the procedure findings, including any pathology identified

Post-Procedure Monitoring

• Check serum creatinine on postoperative day 1, especially after bilateral procedures or in patients with pre-existing renal impairment 1
• Observe for signs of contrast reaction, infection, or ureteral injury
• For patients with suspected ureteral injury during the procedure, place a ureteral stent; if stent placement fails, proceed to percutaneous nephrostomy 4

Technical Considerations and Pitfalls

Never perform blind basketing (stone extraction without endoscopic visualization) due to the high risk of ureteral injury. 5

• Technical success rates for retrograde ureteral procedures approach 90-95% in most clinical scenarios 6
• Failure to cannulate the ureteric orifice is the most common cause of technical failure (7% of cases) 2
• In patients with difficult anatomy (e.g., transplant kidneys with unfavorable ureteral angulation), the rigid cystoscope sheath can serve as a platform through which a flexible ureteroscope is passed 7
• For patients with renal insufficiency where intravenous contrast is contraindicated, retrograde pyelography provides detailed collecting system visualization without systemic iodine exposure 1