Cystoscopy and TRUS PROSTATE BIOPSY (OR)
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SURGEON: Dr. ____
ASSISTANT: Dr. ____
PREOPERATIVE DIAGNOSIS: Elevated PSA
POSTOPERATIVE DIAGNOSIS: Elevated PSA
PROCEDURE: Cystourethroscopy, transrectal ultrasound guided prostate biopsy
FINDINGS: 1.Unremarkable urethra and bladder gram prostate. 2. Unremarkable urethra and bladder
ANESTHESIA: General with LMA
INTRAVENOUS FLUIDS: IV crystalloid
ESTIMATED BLOOD LOSS: Unable to determine due to dilution
TUBES AND DRAINS: None
INDICATIONS FOR PROCEDURE: The patient is a _ yr old who has a history of elevated PSA . Dr. discussed the options with the patient who has agreed to have a cystourethroscopy and 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 cystoscopy suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. IV antibiotics including 900mg clindamycin and 240mg of gentamicin were administered. IV sedation and general anesthetic were administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Time out was performed confirming patient, procedure, side, all in the room agreed. SCDs were on and functioning A well lubricated 22 french cystoscopic sheath with a 30 degree lens was inserted into the urethral meatus and advanced into the bladder. Care was taken to keep the lumen in the center of view. In the urethra there were no urethral strictures, no mucosal lesions, no tumors, no polyps. The prostate was moderately enlarged and was not obstructive in nature. Upon entering the bladder, the bladder was drained. Urine was clear and was not sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion using the 30 degree lens ,then 70 degree lens There were no mucosal lesions, no trabeculations, no diverticulum ,no stones and no tumors .. The bladder was then drained. All parts of the cystoscopic sheath, cystoscope and all instruments were intact and removed from the patient. The patients abdomen was then palpated to ensure there was no change in physical exam. The ultrasound probe was then inserted in the rectum. The prostate was measured and found to be 45 grams resulting in a final PSA density of ___ At this point 12-core prostate biopsies were obtained, they are obtained from the right and left 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 was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well. Please note that Dr. was present throughout the entire length of the procedure.
PLAN: The patient will be discharged after meeting anesthesia criteria. Patient was given given prescriptions for ciprofloxacin for 2 days, norco and miralax. Discussed with patient the dangers of opioid addiction, how to properly dispose of an expired, unused, or unwanted controlled substance, the fact that delivery of a controlled substance is a felony under Michigan Law, the fact that opiates should not be taken with alcohol, sedatives or other central nervous system acting medications patient should not drive or make important decisions within 6 hours of taking an opiod and discussed the short and long-term effects of exposing a fetus to an opioid. Patient acknowledged and communicated understanding of while not under effects of anesthesia prior to the procedure. The 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 will follow up with Dr. in 1-2 weeks.