Urology Operation Note Key

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PATIENT NAME: XXXX

MEDICAL RECORD NUMBER: XXXX

DATE OF OPERATION: XXXX

ANESTHESIA: General endotracheal anesthesia

PREOPERATIVE DIAGNOSIS: Right distal ureteral calculus.

POSTOPERATIVE DIAGNOSIS: Right distal ureteral calculus.

PROCEDURE:

1. Cystolitholapaxy.

2. Right ureteral stent placement, 6 French by 26 cm.

3. Right retrograde pyelogram.

COMPLICATIONS: None.

DRAINS:

24 french 3 way Foley with 30 cc of sterile water in the balloon
Right ureteral stent placement, 6 french by 26 cm.

FLUIDS: 1700 cc crystalloid.

ESTIMATED BLOOD LOSS: Minimal.

FINDINGS:

1. 9 mm right distal ureteral calculus.

2. Trilobar prostatic enlargement with obstructive appearance.

SPECIMEN: Stone.

CONDITION: Stable.

SUMMARY: The patient was taken to the operating room and placed in the supine position. After induction of general endotracheal anesthesia, he was placed in the dorsal lithotomy position. He was prepped and draped in the usual sterile fashion. The 22 French rigid cystoscope was introduced. The urethra was examined and appeared normal. The prostate was reached and had trilobar enlargement with obstructive appearance. The bladder was easily entered. The left ureteral orifice was very small and had clear reflux of urine. The right ureteral orifice had a 9 mm calculus hanging off of it. When filling the bladder with a cystoscope, this stone fell into the bladder.

The 1000 micron holmium laser was introduced through the cystoscope and this calculus was fragmented using the laser. The fragments were then removed with the Ellik evacuator, using the cold cut biopsy forceps to remove the large fragments. The right ureteral orifice was very edematous and could not be seen well to perform a right retrograde pyelogram. Therefore, indigo carmine was given intravenously. It took 20 minutes to see indigo carmine efflux from either ureteral orifice, at which time, it did efflux from both. The open-ended catheter was then passed through the cystoscope and a glidewire was passed up the ureter to the kidney under fluoroscopic vision. The open-ended catheter was then passed over the glidewire up to the mid-ureter and the glidewire was removed. Hypaque contrast was injected through the open ended catheter, performing a right retrograde pyelogram. The right collecting system appeared normal without any hydronephrosis or evidence of filling defects. There was drainage of Hypaque down the ureter, which drained easily. The distal ureter appeared dilated, but there was no evidence of filling defects. The glidewire was then passed up through the open-ended catheter to the kidney under fluoroscopic vision. The open-ended catheter was removed, leaving the wire in place. A 6 French by 26 cm right double-J ureteral stent was passed over the glidewire, and the glidewire was removed. A curl was seen in the upper pole of the right kidney under fluoroscopic vision and a curl was seen in the bladder under cystoscopic vision. I attempted passing a Foley catheter and was unsuccessful doing so. I attempted passing it with a catheter guide and was still unsuccessful. Therefore, the 24 French 3-way Foley catheter had the end hole punched. The 22 French rigid cystoscope was reintroduced into the bladder and the glidewire was passed into the bladder under cystoscopic vision. The 24 French 3-way Foley catheter was then passed over the glidewire into the bladder and urine drained light pink. 30 cc of sterile water was placed in the balloon. The bag was then put to drainage. The patient tolerated the procedure well. He was extubated, and taken to post-anesthesia care unit in satisfactory condition. Sponge and instrument counts were correct at the end of the case.