PLEASE NOTE THESE ARE EXAMPLES, READ THROUGH THE ENTIRE OP REPORT TO ENSURE YOUR OP REPORT IS ACCURATE ACCORDING TO WHAT YOU ACTUALLY DID
1. with surrounding mucosa
ESTIMATED BLOOD LOSS:
TUBES AND DRAINS:
INDICATIONS FOR PROCEDURE: The patient is a who has a history of . Dr. discussed the options with the patient who has 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, 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 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 french cystoscopic sheath with a 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 Upon entering the bladder, the bladder was drained. Urine was sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion We began by identifying with surrounding mucosa This was resected using the loop. Care was taken to take appropriately deep swipes with the loop without perforating the bladder, to resect the base of the bladder tumor There was obturator reflex encountered. After resecting, hemostasis was obtained. We then completely evaluated all surfaces of the bladder while finding mucosal lesions, trabeculations, diverticulum, stones and tumors.. The bladder was again evaluated for hemostasis and then was drained, refilled and the bladder was evaluated closely again for hemostasis, which was . All clots were evacuated from the bladder. 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 after meeting anesthesia criteria. Patient was given given prescriptions for . 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