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: Bladder tumor
POSTOPERATIVE DIAGNOSIS: Bladder tumor
PROCEDURE: Cystourethroscopy, transurethral resection of bladder tumor
1.a single 2cm papillary left lateral wall bladder tumor with surrounding mucosa that was normal
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: Bladder mucosa
INDICATIONS FOR PROCEDURE: The patient is a yr old who has a history of bladder tumor. Dr. discussed the options with the patient who has agreed to have a cystourethroscopy and transurethral resection of bladder tumor. 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, bladder and ureter perforation 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 2g of ancef 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 We began by identifying a single 2cm papillary left lateral wall bladder tumor with surrounding mucosa that was normal. 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 completely and obtain muscle. There was no obturator reflex encountered. After resecting, complete hemostasis was obtained. We then completely evaluated all surfaces of the bladder while finding nomucosal lesions, no trabeculations, no diverticulum, no stones and no tumors.. The bladder was again evaluated for hemostasis and then was drained, refilled and the bladder was evaluated closely again for hemostasis, which was excellent. 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 discharged after meeting anesthesia criteria. Patient was given given prescriptions for norco and mirilax . 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.