Cystoscopy, L Ureteroscopy, Retrograde Pyelogram, stent removal: Female
Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did
SURGEON: Dr. _
ASSISTANT: Dr. _
PREOPERATIVE DIAGNOSIS: Left ureteral calculus
POSTOPERATIVE DIAGNOSIS: Left ureteral calculus
PROCEDURE: Cystourethroscopy, left ureteroscopy, laser lithotripsy, left retrograde pyelogram, left ureteral stent removal
FINDINGS: Unremarkable bladder, urethra, and left collecting system
ANESTHESIA: General with LMA
INTRAVENOUS FLUIDS: IV crystalloid
ESTIMATED BLOOD LOSS: None
TUBES AND DRAINS: None
INDICATIONS FOR PROCEDURE: The patient is a __ yr old who has a history of left nephrolithiasis. Dr. discussed the treatment options with patient who has agreed to have a cystourethroscopy, left ureteroscopy, laser lithotripsy and left retrograde pyelogram. The patient knows there may need to be a ureteral stent left in place. 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 and complications from anesthesia and other complications were discussed, 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 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 urethra lumen in center of view to minimize trauma and damage to the urethra. 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 no mucosal lesions, no trabeculations, no diverticulum, no stones and no tumors. Our attention was directed towards the left ureteral orifice which had a ureteral stent that was grasped with the flexible wire graspers and brought out of the urethral meatus. A sensor wire was used to cannulate the ureteral stent and advanced up to the renal pelvis, this was confirmed with fluoroscopy. The old stent was then removed over the wire while keeping the sensor wire in place with the end in the renal pelvis, again confirmed by fluoroscopy. A second sensor wire was then placed in the ureteral orifice to act as a safety wire. A semirigid ureterscope was then used to survey the ureter on this side being careful to go alongside the wire and keeping the center of the lumen of the urethra and then the ureter in view. The semirigid ureteroscope was able to cannulate the ureteral orifice easily with no resistance and no mucosal flap formation. The stone was then encountered in the ureter and laser lithotripsy was used to break the stone up into pieces that were removed using the wire basket grasper and dropped in the bladder using the semi-rigid ureterscope. The pieces remaining were too small to basket and should likely pass easily. 7cc of conray die where then injected into the semirigid ureteroscope irrigation port to deliniate the collecting system. There was no hydronephrosis, no blunting of the calyces, no extravasation, no filling defects or strictures. There were no stones viewed on plain film the semirigid ureteroscope was then withdrawn from the ureter and bladder and removed with all pieces intact. A flexible ureteroscope was then advanced over the wire and advanced up to the renal pelvis, being careful to keep the lumen in center of view and meeting no resistance as it was advanced. The upper, mid and lower poles were evaluated under direct vision and there were no other stones noted and the flexible ureteroscope was removed with all parts intact. The bladder was drained. Stone specimen were removed using the cystoscopic sheath and stone specimen were sent for pathology. All parts of the cystoscopic sheath, cystoscope and all instruments were intact and removed from the patient. The abdomen was palpated with no change in physical exam and 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 norco, miralax and flomax . 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.