Cystoscopy and TRUS PROSTATE BIOPSY (OR)
Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did.
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FINDINGS: 1. gram prostate.
ESTIMATED BLOOD LOSS:
TUBES AND DRAINS:
INDICATIONS FOR PROCEDURE: The patient is a yr old who has a history of . Dr. discussed the options with the who agreed to have a 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 were discussed, 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 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. A well lubricated french cystoscopic sheath with a 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 The prostate was enlarged and was obstructive in nature. Upon entering the bladder, the bladder was drained. Urine was and was sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion There were , trabeculations, , and .. 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 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. 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 after meeting anesthesia criteria. Patient was given given prescriptions for The 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