DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left ureteropelvic junction stone.
POSTOPERATIVE DIAGNOSIS: Left ureteropelvic junction stone.
OPERATION PERFORMED:
1. Cystoscopy.
2. Left ureteral catheterization.
3. Left extracorporeal shock-wave lithotripsy.
SURGEON: John Doe, MD
ANESTHESIA: General.
SPECIMENS: None.
DRAINS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old gentleman who developed left flank pain. CT scan showed the patient to have a left 6 x 4 mm stone at the left ureteropelvic junction. There was no significant hydronephrosis associated with this. Based upon this, we discussed the options with him and discussed that we would do ureteral catheterization and push the stone into the renal pelvis and then perform left extracorporeal shock-wave lithotripsy.
DESCRIPTION OF OPERATION: The patient was brought to the procedure room and placed on the table in the supine position. He was given general anesthetic, and he was intubated. He was then placed in low lithotomy. The patient was draped and prepped in a sterile fashion. We passed a 22.5 rigid cystoscope with the 12 degree lens into the urethral meatus. Urethroscopy was normal. The scope was then advanced into the bladder. The ureteral orifices were normal caliber and location. There were no other masses or lesions in the bladder. This was a negative cystoscopy. The left ureteral orifice was intubated with a 5 French Pollack catheter. This was passed to the level of the stone under fluoroscopic image and then using a short burst of sterile water, we were able to dislodge the stone, and it was pushed up into the renal pelvis. At this time, we used fluoroscopic imaging to image the stone, and using the Monolith lithotripter device, we applied 1800 compressions on the stone. We had significant fragmentation. There was only small sand-type debris noted at the end of the case. The patient was then transferred to the postoperative care unit in stable condition. The patient will follow up in one week with KUB.
