Cystoscopy and Lithotripsy Medical Transcription Sample
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
Left distal ureteral calculus and left renal colic.
POSTOPERATIVE DIAGNOSES:
Left distal ureteral calculus and left renal colic with bilateral nephrolithiasis.
OPERATION PERFORMED:
1. Cystoscopy.
2. Left retrograde pyelogram.
3. Left ureteroscopy with laser lithotripsy.
4. Left ureteral stent placement.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: After successful general anesthesia was obtained, the patient was placed in the lithotomy position. The lower abdominal area was prepped and draped in the usual manner. Cystoscopy was performed using a 21 French cystoscope with both 30 and 70 degrees oblique lenses. The urethra appeared to be normal. The prostatic fossa was about 2 cm in length and nonocclusive. The bladder showed no mucosal lesions. There was grade 2/4 trabeculation.
The left ureteral orifice was cannulated with 0.038 guidewire, and the left distal ureter was dilated to 6 French to 18 French by 4 cm balloon dilator. The left distal ureter was dilated for approximately 2 minutes at less than 10 atmospheres of pressure. Uteroscopy was performed using the Wolf 8.5 French uteroscope. This showed the stone to be partially already fragmented, possibly from the balloon, and it could possibly be removed with a basket. The stone was placed into the basket, however, it would not come out the orifice. So at this point, the Holmium laser was used at 3.6 watts and a subsequent total of 360 joules of energy was used. The stone was completely disintegrated to small pieces. The basket was then removed.
The uteroscopy was performed an additional couple of times, and there were no stone fragments remaining by the end of the procedure. There were some small amounts of tiny granules in the bladder, which were irrigated out. To be on the safe side, a 6 French x 26 cm double pigtail catheter was placed up into the left kidney, and it was left with a string, which was taped. The patient tolerated the procedure well.
Cystoscopy and Lithotripsy Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ureteral calculus.
POSTOPERATIVE DIAGNOSIS: Ureteral calculus.
OPERATION PERFORMED:
1. Cystoscopy.
2. Retrograde pyelography.
3. Stone basketing, double-J stent insertion.
3. Laser lithotripsy.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION: After the patient was anesthetized, she was prepped and draped in the usual fashion for cystoscopy. The scope was passed under direct vision. Retrograde pyelography confirmed dilated ureter with an obstructing stone. Two guidewires were passed, and the rigid endoscope was passed up into the ureter. The stone was visualized, but it was difficult to get the laser fiber successfully on it. In the process of lasering the stone and getting a basket around it, the stone was manipulated back into the kidney with the water flow.
We next then passed over the second wire the flexible ureteropyeloscope into the kidney. Because the kidney was hydronephrotic and had quite bit of debris in it, the visibility was poor. We finally found the stone once and attempts to get the laser fiber there was unsuccessful. Because of the illness that the patient had, we felt continued manipulation would not be justified and double-J stent was placed. A 24 cm long Polaris 5 French was placed. The bladder was emptied, and the patient was taken to the recovery room.
