Transurethral Resection of Prostate Transcription Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Urinary retention and prostatic hyperplasia.
POSTOPERATIVE DIAGNOSIS:
Urinary retention and prostatic hyperplasia.
OPERATION PERFORMED:
1. Cystoscopy.
2. Urethral dilation.
3. Transurethral resection of prostate.
ANESTHESIA: Spinal.
DESCRIPTION OF OPERATION: After successful spinal anesthesia was obtained, the perineal and pubic regions were prepped and draped in the usual manner. A cystoscopy was performed using a 22 French cystoscope of both 30 and 70-degree oblique lenses. The urethra appeared to be normal. The prostatic fossa was about 2 cm in length and mildly occlusive from trilobar prostatic enlargement. The bladder showed some catheter trauma proximally. There were no significant bladder lesions noted. Ureteral orifices were well recessed from the bladder neck. There was grade 4 out of 4 trabeculation with some cellules in the proximal bladder. The urethra was dilated to 30 French and then the 28 French resectoscope was placed into the bladder with an obturator. The resection was begun at the upper outer quadrant down to the capsule and in the outer lower quadrants to the capsule. Meticulous hemostasis was obtained. The ureteral orifices were checked and were preserved. The prostatic chips were sent for permanent analysis. Estimated resection was approximately 10 grams. A 22 French two-way Foley catheter was placed, and irrigated crystal clear. Estimated blood loss approximately 100 mL. The patient tolerated the procedure well.
Transurethral Resection of Prostate Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Benign prostatic hypertrophy.
2. Severe lower urinary tract symptoms.
3. History of bladder cancer.
POSTOPERATIVE DIAGNOSES:
1. Benign prostatic hypertrophy.
2. Severe lower urinary tract symptoms.
3. History of bladder cancer.
OPERATIONS PERFORMED:
1. Cystoscopy.
2. Holmium transurethral resection of prostate.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: After obtaining consent, the patient was taken to the operating room and placed in supine position. General anesthesia was administered. He was placed in the lithotomy position, prepped, and draped in the normal sterile fashion. The patient received perioperative antibiotics and a suppository. Using a 22.5 French cystoscope and 12- and 70-degree lenses, an ostomy was performed. The anterior urethra was normal. There was a wide caliber stricture in the bulbar urethra. The membranous urethra was normal. The verumontanum was flat. The prostatic urethra was fairly short, measuring approximately 2 cm in length. There was minimal prostatic hypertrophy. The bladder neck appeared moderately open. Survey of the bladder with a 70-degree lens showed no papillary lesions, tumor, stones, or other abnormalities. Bladder capacity was adequate. There was moderate trabeculation of the bladder.
Using the Holmium laser fiber and Holmium set at approximately 80 watts, the prostate tissue was ablated circumferentially. This was more preferentially treated on the right-hand side. After assuring proper hemostasis, a 20 French coude catheter was placed. There was clear pink urine obtained. Rectal exam showed a less than 30 gram prostate without nodules. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Transurethral Resection of Prostate Sample Report #3
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Obstructive uropathy.
2. Benign prostatic hypertrophy.
POSTOPERATIVE DIAGNOSES:
1. Obstructive uropathy.
2. Benign prostatic hypertrophy.
OPERATION PERFORMED: Transurethral resection of prostate.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: After induction of general anesthesia, the patient was placed in the modified lithotomy position. Genitalia prepped and draped in the usual sterile fashion. The 26 French resectoscope sheath was inserted, and bladder was carefully surveyed. Bladder revealed 1+ trabeculations and otherwise normal mucosa. Prostate showed irregular regrowth of the prostate with most of the obstruction occurring from regrowth of the right lobe and ceiling from the 9 o’clock to 12 o’clock positions. The left lobe was nonobstructive. Using the Olympus continuous flow resectoscope with bipolar cautery, a transurethral resection of the regrowth of the prostate, particularly the right lobe, was performed from the bladder neck to the verumontanum keeping all resection proximal to the verumontanum. A wide open prostatic fossa was created in this fashion. All chips were irrigated free from the bladder with Toomey syringe, and hemostasis was meticulously obtained prior to removing resectoscope and inserting #22 three-way Foley catheter. There was no significant bleeding. The procedure was well tolerated by the patient without complications, and the patient was taken to the recovery room in stable condition.
