MRI FUSION TRUS PROSTATE BIOPSY

Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did. If you see an error or way to may this better please contact us.

SURGEON: Dr.__.

ASSISTANT: Dr. __

PREOPERATIVE DIAGNOSIS: elevated PSA

POSTOPERATIVE DIAGNOSIS: elevated PSA

PROCEDURE: Transrectal ultrasound guided prostate biopsy

FINDINGS: 45 gram prostate

ANESTHESIA: Local with sedation

INTRAVENOUS FLUIDS: IV crystalloid

ESTIMATED BLOOD LOSS: <5ml

TUBES AND DRAINS: None

SPECIMENS: 12 core prostate biopsy

COMPLICATIONS: None

INDICATIONS FOR PROCEDURE:  The patient is a __ yr old who has been evaluated recently for elevated PSA. Dr. discussed the options with the patient who has agreed to have a MRI fusion transrectal ultrasound guided prostate biopsy. Prior to the procedure today, the patient's history and physical was reviewed. Informed consent was obtained and all questions were satisfactorily answered. The risks and benefits of the procedure including pain, damage to organs, bleeding, hematoma, infection, sepsis and complications from anesthesia and other complications were discussed, the patient acknowledged and communicated understanding of these risks and wished to proceed with the procedure.

 

OPERATIVE DETAIL:  The patient was transferred to the operating room suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia.  Antibiotics including 900mg clindamycin and 240mg gentamicin antibiotics given.  IV sedation and general anesthetic were administered.  The patient was placed in the lateral recumbant position and time out performed confirming team member introduced by name and role, patient confirmed with 2 identifiers, pre-op diagnosis, procedure to be performed, position and site/side confirmed, allergies reviewed, equipment/implants reviewed, images/radiographic films reviewed, meds and fluids for irrigation reviewed, DVT prophylaxis reviewd, beta blockers/antibiotics usage, glycemic control, blood product availability, warming measures in place and fire risk with all in agreement and with Dr. ___ present for time out. The case began with ultrasound probe was inserted in the rectum. MRI fusion technology was used to overlay the MRI fusion biopsy with the tranrectal ultrasound image. There was one area of interest located in the lateral The prostate was measured and found to be 45cc resulting in a final PSA density of ____ ng/cc/ml. The region of interest was biopsied. A total of ___ biopsies were obtained. At this point 12-core prostate biopsies were obtained, they are obtained from the right and portions of the prostate and on each side were taken from the apex, medial and base with biopsy taken from the medial and lateral portions of each of the respected spots. These were then sent in formalin and sent for pathological examination. The needle biopsy was dipped in formalin between each biopsy. At the end of the procedure, the probe was removed. Pressure was held on the prostate and good hemostasis was noted. The patient tolerated the procedure well and was transferred to PACU in stable condition. Dr. ___ was present throughout the entire procedure.

 

PLAN:  The patient will be discharged home after meeting anesthesia criteria.  Prescriptions for norco, miralax and were provided. ciprofloxacin for___daysThe patient understands if there is any nausea, vomiting, fever, chills or develops gross hematuria, persistent or new pain or symptoms to come back to the Emergency Room for evaluation by urologic surgery. Patient to follow up with Dr. _ in 1-2 weeks for follow up appointment.