Cystoscopy, R Ureteroscopy, Retrograde Pyelogram, stent removal: Male
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: Right nephrolithiasis
POSTOPERATIVE DIAGNOSIS: Right nephrolithiasis
PROCEDURE: Cystourethroscopy, right ureteroscopy, right retrograde pyelogram
FINDINGS: Unremarkable bladder, urethra, prostate, and right 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 right nephrolithiasis. Dr. discussed the treatment options with patient who has agreed to have a cystourethroscopy, right ureteroscopy, right 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/prostate/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 advance 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. The prostate was notenlarged and was non 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 no mucosal lesions, no trabeculations, no diverticulum, no stones and no tumors. Our attention was directed towards the right ureteral orifice which a sensor wire was used to cannulate the right ureteral orifice and advanced up to the renal pelvis, this was confirmed with fluoroscopy. sensor A flexible ureteroscope was then used over the wire 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 flexible ureteroscope was able to cannulate the ureteral orifice easily with no resistance and no mucosal flap formation. Upon entering the renal pelvis, the wire was removed and a retrograde pyelogram was shot with 7 cc of conray die into the irrigation port to delineate 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 upper, mid and lower poles were then evaluated under direct vision and there were no other stones noted and the flexible ureteroscope was slowly withdrawn from the ureter, keeping the middle of the lumen in view at all times and carefully surveying for stones. There were no more stones appreciated. The flexible ureteroscope was then the removed with all parts intact.The bladder was then drained using the cystoscopic sheath with obturator. 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.