Cystoscopy / Botox
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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SURGEON: Dr. ____ ASSISTANT: Dr. ____ PREOPERATIVE DIAGNOSIS: Overactive bladder POSTOPERATIVE DIAGNOSIS: Overactive bladder PROCEDURE: Cystourethroscopy, botox injection FINDINGS: 1.Unremarkable bladder; 2. Unremarkable urethra ANESTHESIA: General with LMA INTRAVENOUS FLUIDS: IV crystalloid ESTIMATED BLOOD LOSS: Unable to determine due to dilution TUBES AND DRAINS: None SPECIMENS: None COMPLICATIONS: None INDICATIONS FOR PROCEDURE: The patient is a _ yr old who has a history of overactive bladder. Dr. discussed the options with the patient who has agreed to have a cystourethroscopy with botox injection. 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 including the ureter, kidney, bladder, urethra, bleeding, pain, infection, bladder and ureter perforation 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 1g ampicillin and 240mg gentamycin 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 advance 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. Upon entering the bladder, the bladder was drained. Urine 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 nomucosal lesions, no trabeculations, no diverticulum, no stones and no tumors.. Both ureteral orifices were identified and botox injections were ensured to begin 2cm superior and lateral to the ureteral orifice. 100 units of botox was mixed in 10cc of sterile water and the 10cc of botox was injected in 10different spots, 1ml in each spot in the bladder starting in the left lateral wall and progressing 1-2cm apart to the right lateral wall for 5 injections, then another row of injections 1-2 cm superior to this row was injected in similar fashion. A 2ml flush was used to ensure all botox was injected. The bladder was evaluated to ensure hemostasis was obtained, there was no active bleeding. 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 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 nothing at this time . 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.
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SURGEON: Dr. ____ ASSISTANT: Dr. ____ PREOPERATIVE DIAGNOSIS: Overactive bladder POSTOPERATIVE DIAGNOSIS: Overactive bladder PROCEDURE: Cystourethroscopy, botox injection FINDINGS: 1.Unremarkable bladder; 2. Unremarkable prostate and urethra ANESTHESIA: General with LMA INTRAVENOUS FLUIDS: IV crystalloid ESTIMATED BLOOD LOSS: Unable to determine due to dilution TUBES AND DRAINS: None SPECIMENS: None COMPLICATIONS: None INDICATIONS FOR PROCEDURE: The patient is a _ yr old who has a history of overactive bladder. Dr. discussed the options with the patient who has agreed to have a cystourethroscopy with botox injection. 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 including the ureter, kidney, bladder, urethra, bleeding, pain, infection, bladder and ureter perforation 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 1g ampicillin and 240mg gentamycin 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 advance 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 not not enlarged and was not not obstructive. Upon entering the bladder, the bladder was drained. Urine 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 nomucosal lesions, no trabeculations, no diverticulum, no stones and no tumors.. Both ureteral orifices were identified and botox injections were ensured to begin 2cm superior and lateral to the ureteral orifice. 100 units of botox was mixed in 10cc of sterile water and the 10cc of botox was injected in 10 different spots, 1ml in each spot in the bladder starting in the left lateral wall and progressing 1-2cm apart to the right lateral wall for 5 injections, then another row of injections 1-2 cm superior to this row was injected in similar fashion. A 2ml flush was used to ensure all botox was injected. The bladder was evaluated to ensure hemostasis was obtained, there was no active bleeding. 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 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 nothing at this time . 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.
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