DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right ureteral obstruction.
POSTOPERATIVE DIAGNOSES:
1. Right ureteral obstruction.
2. Right ureteral stricture.
PROCEDURE PERFORMED:
1. Cystoscopy.
2. Right ureteroscopy.
3. Balloon dilation of right distal ureter.
4. Placement of right double-J ureteral stent.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old gentleman who now is two weeks status post ureteroscopy and laser lithotripsy of a ureteral stone on the right side who, since his stent was removed, has complained of right flank pain, recently worsening. The patient had an IVP yesterday, which showed significant hydronephrosis down to the ureterovesical junction on the right. The patient was, therefore, scheduled for ureteroscopy and possible basketing of a ureteral stone fragment or balloon dilation of a ureteral stricture.
DESCRIPTION OF PROCEDURE: After induction of general anesthesia, the patient was placed in the modified lithotomy position. Genitalia prepped and draped in the usual sterile fashion. A #21 French cystoscope was inserted under camera vision. Urethra was unremarkable with no strictures or lesions. Prostate was nonobstructive in nature and scope was passed into the bladder and bladder was carefully surveyed with all lenses. Bladder mucosa was normal other than significant edema and erythema surrounding the right ureteral orifice.
A guidewire was successfully placed up the right ureter under fluoroscopic control. No stones could be seen on fluoroscopy. A rigid ureteroscope was then negotiated alongside the guidewire into the right intramural ureter. The right intramural ureter had significant edema, and there appeared to be a strictured area of the mid and proximal intramural ureter. This was tight to the scope. There was, however, no stone fragment seen. The ureter proximal to the intramural ureter was significantly dilated and otherwise unremarkable.
The ureteroscope was passed up to the mid ureter, and no stone fragments were found. We decided to balloon dilate the right intramural ureter to help improve drainage from the right kidney. The 4 cm length of balloon catheter was placed over the guidewire, positioned on fluoroscopy and cystoscopically in good position and then inflated to approximately 16-18 atmospheres for 5-10 minutes.
After successful balloon dilation, the balloon dilating catheter was deflated and removed and a double-J stent was placed over the guidewire, size 24 cm length, #5 French diameter. The guidewire was then removed after the stent was well positioned. The stent was left on a string so that it could be removed in several days without requiring cystoscopy.
The procedure was well tolerated by the patient without complication. The patient was taken to the recovery room in stable condition.
