Cystourethroscopy Medical Transcription Example Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Asymptomatic microhematuria.
POSTOPERATIVE DIAGNOSIS:
Asymptomatic microhematuria.
OPERATION PERFORMED:
1. Cystourethroscopy.
2. Right retrograde pyelography.
3. Attempted left retrograde pyelography.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the cystoscopy suite for cystourethroscopy and above procedures. After adequate instillation of general anesthesia, the patient was placed in the lithotomy position. He was prepped and draped in the usual sterile fashion. A 21 French cystoscope with a 12 degree lens was inserted through the urethral meatus and advanced under direct visualization with continuous irrigation. The anterior urethra was normal; specifically, there was no evidence of urethral stricture. The posterior urethra was unremarkable; specifically, minimal stigmata consistent with benign prostatic hypertrophy in the form of mild enlargement of lateral lobes but no significant elevation of the median bar. The supramontanal length was 2.5 to 3 cm. The prostatic urethra was obstructed. The cystoscope was advanced, passed an intact bladder neck into the bladder. Urine was obtained for culture and cytology.
The bladder was thoroughly visualized with the 12 and 70 degree lenses. Cytoscopy was unremarkable. The trigone of the bladder was normal. The ureteral orifices were in an orthotopic position and effluxed clear urine. The anterior wall, posterior wall, lateral wall and dome of the bladder wall visualized and found to be normal. The bladder was without significant trabeculation, cellularity, and/or diverticula. The bladder was without stone. The bladder mucosa was without lesion. Specifically, there was no evidence of bladder tumor, acute/chronic inflammatory stigmata, and/or mucosal changes to suggest carcinoma in situ. Once cystoscopy was completed, attention was turned to the trigone. Due to clinical uncertainty, the decision was made to proceed with retrograde pyelogram.
Right retrograde pyelography was performed with an 8 French cone-tipped catheter. The retrograde pyelogram demonstrated normal upper urinary tract. Attention was then turned to the left hemitrigone. The left ureteral orifice could not easily be intubated with the 8 French cone-tipped catheter and therefore in an effort to avoid problems with the left ureteral orifice, a decision was made to avoid retrograde pyelography.
The attention was then turned to the left hemitrigone. Intubation of the left ureteral orifice with the 8 French cone-tip catheter was technically difficult. The ureteral orifice would not easily accept the cone-tip catheter. Under these circumstances, an attempt was made to place a guidewire, but edema of the orifice prevented the passage of the guidewire.
An attempt was made to intubate the left ureteral orifice with the uteroscope, but the edema prevented the passage of the ureteroscope. Decision was made to avoid any further manipulation of the left ureteral orifice. The left retrograde pyelogram was deferred. Once the procedure was completed, the bladder was emptied and the cystoscope was removed under direct visualization and continuous irrigation. A 16 French Foley catheter was inserted into the bladder and placed for gravity drainage after filling the Foley balloon with 10 mL of sterile water.
The patient tolerated the procedure well. He was awakened in the operating room and accompanied to the recovery room in stable condition. The estimated blood loss was negligible. The procedure was performed with approximately 1000 mL of crystalloid. The procedure was performed without transfusion. The procedure was performed without identifiable complications. Specimens included urine culture and urine for cytology. At the completion of the procedure, there were no dressings. Drains included a 16 French Foley catheter to gravity drainage.
