PREOPERATIVE DIAGNOSIS:

 

Ureteral obstruction secondary to clot colic from coagulopathy.

 

POSTOPERATIVE DIAGNOSIS:

 

Ureteral obstruction secondary to clot colic from coagulopathy.

 

OPERATION PERFORMED:

 

1.  Cystoscopy.

2.  Left retrograde pyelogram.

3.  Left ureteroscopy.

4.  Evacuation of clots from left ureter.

 

ANESTHESIA:  General laryngeal mask airway (LMA).

 

ANESTHESIOLOGIST:

 

FINDINGS AND PROCEDURE:  The patient was brought to the surgical suite.  Consent was conferred as to bilaterality.  The patient was then given general LMA anesthesia. After appropriate level was achieved, she was placed in the dorsal lithotomy position, prepped with Betadine and draped in an aseptic fashion.  Then, 2% Xylocaine was infused into bladder.  Endoscope was introduced into the bladder.  There were no clots in the bladder.  The urine was clear.  There was a clot coming out of the left orifice.  Once this clot was removed, there was some discoloration to the urine.  We then placed a cone-tip catheter into the orifice.  It passed without difficulty into entire ureter.  We injected the dye.  The ureter filled without showing signs of hydronephrosis.  The upper collecting system filled promptly, however, there was poor filling of the medial and inferior calices secondary to clot.  However, after this was done, the film showed prompt drainage.  Because of the string of clot in the ureter, we decided to place a guidewire.  Once the guidewire was inserted, the scope was removed and the ureteroscope was placed over the guidewire.  We inserted this into the ureter, and we were able to evacuate the entire string of clots from the ureter.  Therefore, after post evacuation, the ureter was completely open without any signs of obstruction.   After the clot was removed into the bladder, we evacuated the clot from the bladder, and then drained the bladder.  The patient had 2% Xylocaine reinfused into the urethra.  The patient was aroused, extubated, and carried to the recovery room in stable condition.  Postoperatively, the patient is to drink plenty of fluids.  There are no further recommendations other than continue present postoperative care and maintain to control her coagulopathy and, at a later date, she may need to have reassessment of her kidney as far as the function in the lower pole. However, her creatinine is normal.  It has not changed significantly since the admission date, and, therefore, I feel like the kidney is working properly.

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PREOPERATIVE DIAGNOSIS:

 

Multiple right renal calculi.

 

POSTOPERATIVE DIAGNOSES:

 

1.  Right renal calculi.

2.  Urethral stenosis.

 

OPERATION PERFORMED:

 

Cystoscopy with placement of right ureteral stent and extracorporeal shock-wave lithotripsy of multiple renal calculi.

 

ANESTHESIA:  General endotracheal.

 

ANESTHESIOLOGIST: 

 

PROCEDURE:  After the patient's consent was confirmed, the patient was taken to the cysto suite where she was placed on the  cysto table using a Storz table as a modified cystoscopy table.  She was then given general endotracheal anesthesia.  After appropriate level was achieved, placed in the dorsal lithotomy position, she was prepped with Betadine and draped in aseptic fashion, after which 2% Xylocaine was infused into the urethra.  The urethra was somewhat tight.  We had to dilate from an 18-French and a 30-French.  After we dilated the urethra, we placed the cystoscope into the urethra.  The bladder showed normal mucosa without any lesions or tumors.  The orifices were in normal position.  The right orifice was then cannulated with a guidewire.  Once the guidewire was in good position, we then placed the double-J stent, 22-cm, 6-French, over the guidewire.  Once in position, the patient was then taken out of the dorsal lithotomy and positioned over the electrode and extracorporeal shock-wave lithotripsy (ESWL) procedure was carried out as indicated.  The stone in the upper mid calyx was broken up with approximately 1600 shocks.  Then the rest of the shocks were given to the stones in the distal inferior calyx.  This was a large calculus, almost 2 cm, however, the larger stone broke up was ease.  There was a large amount of stone burden that was residual requiring the patient to come back for another treatment with ESWL.  The patient, however, after the procedure, tolerated the procedure well.  She was aroused, extubated, and carried to the recovery room in a stable condition. 

 

She will have a KUB so we can assess the residual calculi and then we will schedule her next procedure as an outpatient.  She will take Ultracet 1-2 tablets q.4-6 h. for severe pain and to use the Percocet, to break in half, if she has pain that is not covered by the Ultracet.  She would also take Pyridium 200 mg every 8 hours for dysuria and use the Macrobid 1 tablet twice a day as an antibiotic.  The patient will follow up in my office in a week and call the office in order to set up for next surgical procedure.

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PREOPERATIVE DIAGNOSES:

 

1.  Left flank pain.

2.  History of multiple kidney stones.

 

POSTOPERATIVE DIAGNOSES:

 

1.  No evidence of any ureteral calculi.

2.  Multiple bladder calculi.

3.  Multiple bladder diverticula with elevated bladder capacity.

 

OPERATION PERFORMED:

 

1.  Cystoscopy with bilateral retrograde pyelography.

2.  Bilateral ureteroscopy.

3.  Evacuation of multiple bladder calculi.

 

ANESTHESIA:  General.

 

INDICATIONS FOR PROCEDURE:  The patient is a 57-year-old gentleman with a long history of passing uric acid kidney stones.  He is unable to tolerate any medication for urinary alkalinization in the past.  He is on allopurinol but has continued to pass multiple stones and was admitted to the hospital with severe left-sided flank pain radiating down to the left lower quadrant.  CT scan of the abdomen and pelvis was performed which revealed somewhat large bladder capacity, what appeared to be stones within the bladder but no evidence of any hydronephrosis or stones along the course of the ureter, although on the left side, there may have been a small punctate stone that possibly within the distal left ureter.  Again, no hydronephrosis was noted.

 

PROCEDURE:  The patient was taken to the operating room, placed in the lithotomy position after general anesthesia was induced.  The patient was prepped and draped in general fashion.  Cystoscopy sheath, #21 French,  placed through urethra and into the bladder under direct vision.  The urethra had normal appearance without stricture or diverticula.  At the bulbous urethra, slight narrowing was noted.  The scope easily passed through this into the prostate, which showed no evidence of any obstruction. 

 

The bladder was then entered.  The bladder had an elevated residual and what was quite apparent was multiple yellowish small stones within the bladder consistent with uric acid stones.  In addition, there was a medium-sized bladder diverticula noted in the posterior bladder wall.  There was also another bladder diverticula noted on the right lateral wall as well.  These were filled with stones as well.  At this point in time, Ellik evacuator was used and probably 95% of the stones were removed from the bladder with irrigation and these were sent for permanent analysis.

 

At this point in time, bilateral retrograde pyelograms were performed in the usual fashion.  These revealed normal ureters bilaterally.  No evidence of any hydronephrosis.  There was good drainage on both sides.  There was a small calcific density noted in the left pelvis overlying the ureteral shadow, but I believe this was a phlebolith not within the ureter; however, at this point in time, the ureteroscope was placed up the ureter on the left side and no stones were visualized.  This was then done on the right side and again no evidence of any ureteral calculi were noted.  At this point in time then, the bladder was drained of irrigating solution, the cystoscopy sheath was removed from the patient. 

 

The patient was awakened from the anesthesia and taken to the recovery room in stable condition, having tolerated the procedure well.  I do not believe he has any ureteral stones and I doubt very much that he has been passing ureteral stones.  Most of the stones I believe are secondary to bladder calculi and at this point in time, we will go ahead and start him on Flomax 0.4 mg a day to try to help him urinate a little bit better as I believe he may have some functional bladder outlet obstruction.  In addition, he can be maintained on his allopurinol and we will attempt to place him on some type of urinary alkalinization regimen so that he can alkalize his urine and prevent further stone formation.  Lastly, I believe this patient will require evaluation for chronic pain and possible narcotic abuse.

 

 

PREOPERATIVE DIAGNOSIS:

 

Microscopic hematuria.

 

POSTOPERATIVE DIAGNOSIS:

 

Microscopic hematuria.

 

OPERATION PERFORMED:

 

1.  Cystoscopy.

2.  Bilateral retrograde pyelogram.

3.  Right ureteroscopy.

 

ASSISTANT:

 

ANESTHESIA:  General with laryngeal mask airway (LMA).

 

ANESTHESIOLOGIST:

 

INDICATIONS:  The patient is a 66-year-old with microscopic hematuria.  Urine cytology and culture were both negative.  The renal ultrasound was normal.  She has an IV contrast allergy, so an IVP was not performed.  She presents for cystoscopy and bilateral retrograde pyelogram.  The risks and potential complications were fully discussed including, but not limited to hematuria, urinary tract infection, bladder perforation, ureteral injury, and alike.  Full consent was obtained.

 

FINDINGS AND PROCEDURE:  After the patient was brought to the operating room, an adequate anesthesia was achieved.  She was placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion.  The 22.5- French cystoscope was introduced per urethra into the bladder.  The bladder was examined with the 30 degree lens and the 70 degree lens.  There was mild pseudomembranous trigonitis.  There were no papillary lesions.  No tumors.  No trabeculation.  The ureteral orifices were orthotopic.  There was clear efflux of urine demonstrated bilaterally.  At this point, the 8-French cone-tipped catheter was used to cannulate the right ureteral orifice.  There were some filling defects in the distal ureter consistent with air bubbles.  There also appeared to be some filling defects in the proximal right ureter at the level of the ureteropelvic junction (UPJ), which also appeared to be air bubbles, but this was persistent despite instilling additional contrast into that system.

 

At this point, it was decided to do a ureteroscopy.  The Glidewire was advanced into the right kidney.  The rigid ureteroscope was introduced and advanced all the way up to the renal pelvis.  There was no ureteral or renal pelvic abnormality identified.  At this point, the 8-French cone-tipped catheter was used to cannulate the left system.  That system appeared normal without any evidence of obstruction or filling defect.  The Glidewire was subsequently removed, as well as the cystoscope. 

 

The patient tolerated the procedure well.  There were no immediate complications.  Prophylactic antibiotics were given.

 

 

PREOPERATIVE DIAGNOSES:

 

Hematuria and elevated prostate-specific antigen.

 

POSTOPERATIVE DIAGNOSES:

 

Hematuria and elevated prostate-specific antigen.

 

OPERATION PERFORMED:

 

1.  Cystoscopy.

2.  Prostate ultrasound biopsy.

 

 

ANESTHESIA:  General with laryngeal mask airway (LMA).

 

ANESTHESIOLOGIST: 

 

INDICATION:  The patient is a 57-year-old with a history of hematuria and an elevated PSA of 4.1.  A urine cytology was negative as well a urine culture.  He had an IVP which was normal.  He had a cystoscopy done in the office which demonstrated mild trabeculations, stone particles, as well as an area of erythema.  He was advised to undergo cystoscopy, bladder biopsy, bilateral retrograde pyelogram, prostate ultrasound, and biopsy.  The risks and potential complications were fully discussed including but not limited to hematuria, urinary tract infection, bladder perforation, urethral injury, hematospermia, blood per rectum, and voiding dysfunction.  Full consent was obtained. 

 

FINDINGS AND PROCEDURE:  After the patient was brought to the operating room and adequate anesthesia was achieved, he was placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion.  The 22.5-French cystoscope with the 30-degree lens was introduced per urethra to the bladder.  The anterior urethra was normal.  The prostatic urethra measured about 3 cm.  There was mild visual obstruction when viewed from the verumontanum.  Endoscopy of the bladder demonstrated no areas of erythema.  No papillary tumors.  There were some stone particles, very small, on the floor of the bladder.  Both ureteral orifices were orthotopic.  There was clear efflux of urine demonstrated bilaterally.

 

The 8-French cone-tip catheter was attempted to cannulate both ureteral orifices, but this was unsuccessful and consequently retrograde pyelograms were not performed.  There was some mild bleeding noted at the bladder neck.  The Bugbee electrode was used to fulgurate that area, which was done successfully.  The bladder was allowed to be drained.  The ultrasonic probe was then placed per rectum.  The prostate was surveyed from the base to the apex.  There was a distinct hyperechoic area involved in the left lobe.  The seminal vesicles appeared normal.  Sixteen core biopsies were taken from the right and left lobes at the levels of the base, midgland, apex, and transitional zone, right and left respectively.

 

The patient tolerated the procedure well.  There were no immediate complications.  Prophylactic antibiotics were given.

 

 

PREOPERATIVE DIAGNOSES:

 

1.  Advanced metastatic colorectal cancer.

2.  Bilateral ureteral obstruction.

 

POSTOPERATIVE DIAGNOSES:

 

1.  Advanced metastatic colorectal cancer.

2.  Bilateral ureteral obstruction.

 

OPERATION PERFORMED:

 

1.  Cystoscopy.

2.  Bilateral stent exchange.

 

ANESTHESIA:  General with laryngeal mask airway (LMA).

 

INDICATIONS:  The patient is a 77-year-old with a history of metastatic advanced colorectal cancer.  She has had bilateral ureteral obstruction and presents for bilateral stent exchange.  Informed consent was obtained.

 

FINDINGS AND PROCEDURE:  After the patient was brought to the operating room and adequate anesthesia was achieved, she was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.  The 22.5-French cystoscope was introduced per urethra into the bladder.  The bladder was examined.  There was recurrent colorectal cancer invading into the bladder.  There were multiple nodular areas.  There were some bullous changes involving the ureteral orifices.  Both ureteral stents were seen emanating from their respective ureteral orifices.  The right ureteral stent was grasped and brought out through the ureteral meatus.  A 6-French 26 cm double-J stent was then placed over the Glidewire, which was advanced up into the kidney.  In a similar fashion, the left system was approached.  The alligator grasping forceps were used to grasp the stent, which was brought out through the urethral meatus.  A 0.038 Glidewire was inserted into the ureteral stent.  The stent was subsequently removed.  A 6-French 26 cm double-J ureteral stent was placed.  There was a good curl in the kidney, as well as in the bladder. 

 

In light of the fact that the patient has recurrent colorectal cancer invading the bladder cancer, it was decided not to do a transurethral resection (TUR), but to discuss this with the medical oncologist and whether or not additional chemotherapy would be recommended.  I will wait to hear from Dr..

 

 

PREOPERATIVE DIAGNOSIS:

 

Pelvic pain.

 

POSTOPERATIVE DIAGNOSIS:

 

Normal laparoscopy except for a small right  functional ovarian corpus luteum cyst..

 

PROCEDURE:

 

Cystoscopy with bilateral ureteral stents and diagnostic laparoscopy.

 

Dr. was present during the procedure to confirm operative findings.

 

PROCEDURE: The patient was first given general endotracheal anesthetic and was then prepped and draped in usual sterile fashion for laparoscopy and cystoscopy.  Cystoscopy was first performed, which revealed normal bladder. Both right and left ureteral orifices were norma and  6-French ureteral catheters were easily inserted to 20 cm.  At this point, an intraumbilical incision was made and gas insufflated to 50 mmHg through Veress needle.  A 5 mm intraumbilical trocar and 5 mm left lower quadrant trocars were placed.  Evaluation revealed an entirely normal pelvis.  There was no left tube and ovary.  Uterus was normal.  Bowel was normal.  Pelvis was normal.  Right and left ureterosacral ligaments were normal.  Both right and left ureters appeared normal.  There appeared to be a functional corpus luteum cyst on the right with normal appearing essentially otherwise normal ovary and tube.  The entire exam was normal.  Appendix was normal.  Liver was normal.  Gallbladder appeared normal.  This was identified and the scope was removed.  The gas was evacuated and the 5 mm trocar was closed with 4-0 Vicryl.

 

 

PREOPERATIVE DIAGNOSIS:

 

Bilateral urolithiasis.

 

POSTOPERATIVE DIAGNOSIS:

 

Bilateral urolithiasis.

 

PROCEDURE:

 

1.  Cystoscopy.

2.  Right retrograde pyelogram.

3.  Right ureteral stent placement.

4.  Right extracorporeal shockwave lithotripsy (ESWL).

 

ANESTHESIA:  Laryngeal mask general.

 

ANESTHESIOLOGIST: 

 

BRIEF CLINICAL HISTORY:  The patient is a 51-year-old white female without prior history of kidney stones.  She underwent parathyroidectomy in February 2004.  She has recently had intermittent right flank pain and an ultrasound showed mild dilation of the right collecting system with a 12 mm stone.  Smaller stones were noted in the left kidney without any hydronephrosis.  This was confirmed on her KUB showing a 12 mm stone in the right mid kidney and three stones on the left measuring 4-5 mm.  She has had followup testing through Dr. showing a 24-hour urine calcium output of only 93 mg.  Her serum calcium level is normal.

 

DESCRIPTION OF THE PROCEDURE:  ESTIMATED BLOOD LOSS:  Minimal.  IV FLUID:  2.3 liters crystalloid.  SPECIMENS:  None.  DRAINS:  A #5 French x 28 cm right double-pigtail ureteral stent and #18 French Foley catheter.  COMPLICATIONS:  None. 

 

The patient was brought to the lithotripsy suite.  After induction of laryngeal mask general anesthesia, she was placed in dorsolithotomy position.  Perineum and introitus were prepped and draped.

 

A #22 French rigid cystoscope was passed per urethra with obturator.  The bladder was drained and then inspected with 12 and 70-degree lenses.  She has a central cystocele.  Both orifices appear normal.  Minimal squamous metaplasia in the bladder neck area and no suspicious mucosal changes elsewhere.  No trabeculation noted.

 

Pollack catheter was threaded into the right ureter and dilute contrast was used to perform segmental pyelogram images on the right.  Distally, multiple pelvic calcifications are lateral to the ureter consistent with phleboliths.  No obvious filling defects seen.  There is mild dilation of the majority of the collecting system above the pelvic brim.  The stone appeared to be free floating within the renal pelvis.

 

A sensor guidewire was threaded up into the kidney.  The Pollack catheter was inserted over the wire and the ureteral length was estimated.  The contrast in the kidney was also allowed to drain to improve visualization of the stone for lithotripsy.  The guidewire was then replaced and the Pollack catheter removed.  A #5 French x 28 cm Polaris double-pigtail stent was then inserted with good pigtail formation on both ends.  Cystoscope was removed and replaced with an #18 French Foley catheter. 

 

Extracorporeal shock wave lithotripsy was then performed on the right kidney stone.  Shock waves were delivered 120 per minute ungated.  There were no arrhythmias.  Shock waves were gradually increased from energy level setting of 1 to a maximum of 8.  The stone appeared to fragment well.  Periodic AP and oblique fluoroscopy was used.  After 2000 shocks, the patient was awakened, extubated, and transported to the recovery room in stable condition.

 

 

PREOPERATIVE DIAGNOSIS:

 

Left renal calculi.

 

POSTOPERATIVE DIAGNOSIS:

 

Left renal calculi.

 

PROCEDURE:

 

1.  Cystoscopy.

2.  Removal of double-J stent.

3.  Flexible nephroscopy.

4.  Stone basket extraction of stones.

5.  Stent placement (5 French x 12 cm with a string).

 

ANESTHESIA:  General.

 

ANESTHESIOLOGIST:

 

HISTORY OF PRESENT ILLNESS:  The patient is a 3-year-old female who has had multiple procedures previously.  She initially had a left percutaneous nephrolithotripsy on August 20, 2002, with a second elected procedure 1 week later.  She has had subsequent treatment approximately 1 year later with a left flexible nephroscopy in October 2003.  She subsequently had bilateral ureteral re-implantation with a right tapered re-implant on December 15, 2003.  She had recurrence of her stone and has now had 2 prior treatments, 2 prior flexible ureteroscopy and nephroscopy with laser lithotripsy.  First is on July 22, 2004, and then subsequently on August 9, 2004.  She presents today for removal of double-J stent and examination for any other stone.

 

INTRAOPERATIVE FINDINGS:  Approximately 8 small stones, no other remaining fragments at the end of the procedure.

 

DESCRIPTION OF OPERATION:  After informed consent, the patient was brought to the operating room and placed in supine position.  General anesthesia was administered.  She was placed in lithotomy position and prepped and draped in the normal sterile fashion.  She received perioperative antibiotics.

 

Using pediatric cystoscope, the distal portion of the stent was identified.  Initially attempt with stone grasper, which was unable to remove the stone.  We used a stone basket to grasp the stone.  The stent brought out through the ureteral meatus.  Guidewire was placed up to the stent.  Using flexible nephroscopy, endoscopy was performed.  There was minimal inflammatory change in the ureter.  There was some redundancy in the proximal ureter.  Passing scope into the upper collecting system, we identified small stones.  We made approximately 8 passes and removed small stone fragments.  These stones fragments were sent for analysis.  We did place a 5-French x12 cm double-J stent with a string attached at the end of the procedure.  Proximal colon identified by fluoroscopy and distal colon by direct vision.  The patient tolerated the procedure well and sent from the operating room to recovery room in stable condition.

 

 

 

 

PREOPERATIVE DIAGNOSIS:

 

Right hydronephrosis with urosepsis with 27-weeks pregnancy.

 

POSTOPERATIVE DIAGNOSIS:

 

Right hydronephrosis with urosepsis with 27-weeks pregnancy.

 

OPERATIONS:

 

1.  Cystourethroscopy.

2.  Right retrograde pyelogram.

3.  Insertion of double J ureteral stent.

 

ANESTHESIA:                        Spinal.

 

INDICATIONS:  This is a 17-year-old female who is pregnant with a 27-week pregnancy.  She was seen to have a high white count with a differential count to the left.  She also had chills and fever.  She has a moderate-to-severe hydronephrosis with positive blood cultures.  The patient has a past history of neurogenic bladder with a similar problem with scarring in the kidney, according to her mother.  The patient was advised for immediate decompression of the right system. 

 

FINDINGS:  The cystoscopy showed a urethral stenosis which was mild.  Trigonitis was present.  The bladder showed no stone or tumor.  It was slightly displaced forward, probably from the gravid uterus.  The ureteral orifices were seen well with clear efflux from the left and minimal on the right.  Retrograde pyelogram was kept to a minimal and no obvious intraluminal pathology was seen. 

 

PROCEDURE IN DETAIL:  The patient was premedicated and brought to the operating room.  Spinal anesthesia was administered.  The patient was placed in the lithotomy position, prepared with Betadine and draped in a sterile manner. 

 

Cystoscopy was carried out with the 21-French cystoscope sheath and the 12 and 70-degree lenses.  The instrument was assembled, passed to the bladder, and the findings are as above.  A 0.035 guide wire was now threaded up the right ureteral orifice into the kidney under fluoroscopy.  Minimal x-ray exposure was used.  A 5-French open-ended catheter was now passed all the way to the right renal pelvis, and a tortuosity of the ureter was obvious on retrograde pyelogram.  The guide wire was now replaced, and over the same, a 6-French, 26-cm, Polaris double J ureteral stent was inserted in the proper place and confirmed with fluoroscopy. 

 

The instrument was then withdrawn, and the bladder was drained with a Foley catheter.  The patient was taken to the recovery room in good condition.

 

 

 

PREOPERATIVE DIAGNOSES:

 

1. Bladder tumor.

2. Benign prostatic hypertrophy.

3. Bladder outlet obstruction.

4. Urinary retention.

 

POSTOPERATIVE DIAGNOSES:

 

1. Bladder tumor.

2. Benign prostatic hypertrophy.

3. Bladder outlet obstruction.

4. Urinary retention.

 

OPERATION PERFORMED:

 

1. Cystoscopy.

2. Transurethral resection of bladder tumor.

3. Holmium laser prostatectomy.

 

ANESTHESIA: General.

 

ANESTHESIOLOGIST:

 

FINDINGS AND PROCEDURE: Drains: 20-French Foley catheter. Complications: None. Estimated blood loss: None.

 

Under general anesthesia in the dorsal lithotomy position, the patient was prepped and draped in a sterile fashion.

 

Cystoscopy revealed some inflammatory changes from a previous Foley catheter. However, there was one lesion that appeared to be a possible transitional cell carcinoma. However, it had more of an inflammatory characteristic today. Using the resectoscope sheath, the lesion was resected and the base was cauterized and the tissue was evacuated. Following this, using a cystoscope with a laser bridge, the Holmium laser was used at 80 watt power to perform a laser prostatectomy. The procedure did not proceed beyond the verumontanum. The ureteral orifice remained intact. The bladder neck was incised. There was no bleeding and the urinary efflux was clear. A 20-French Foley catheter was placed with clear urine efflux.

 

The patient was transferred to the recovery room in satisfactory condition.

 

 

PREOPERATIVE DIAGNOSIS:

 

Symptomatic obstructing right ureteral calculus.

 

POSTOPERATIVE DIAGNOSIS:

 

Symptomatic obstructing right ureteral calculus.

 

OPERATION PERFORMED:

 

Cystoscopy, replacement of a stent.

 

ANESTHESIA:  Laryngeal mask airway.

 

INDICATIONS:  Indications for procedure can be found in the previously dictated consultation note. 

 

FINDINGS AND PROCEDURE:  Estimated blood loss:  None.  Specimens:  Urine culture from right renal pelvis urine culture from right renal pelvis.  Drains:  A 24-cm 6-French double-J ureteral stent.  Complications:  None.

 

After obtaining a written consent, the patient was brought to the cystoscopy suite.  After induction of a laryngeal mask airway anesthesia, she was placed on the table in the dorsal lithotomy position.  The lower abdomen and external genitalia were then prepped and draped in the usual sterile fashion.

 

Cystoscopy was performed using a 22-French Olympus cystoscope.  The bladder contained no tumors, calculi, or diverticula.  Both ureteral orifices were seen.  They were in the normal position with normal shape.  There was clear efflux on the left side; however, minimal efflux from the right side.

 

The guidewire was inserted into the right ureteral orifice.  It was advanced all the way up to the kidney under fluoroscopic guidance.  The stone could still be seen at the level of L4.  Over the guidewire, a 5-French open-ended ureteral catheter was then passed.  It was advanced into the renal pelvis and the wire was removed.  There was not a hydronephrotic drip of urine.  The catheter was aspirated, and very concentrated purulent urine returned.  This was sent for culture and sensitivity. 

 

The wire was placed back into the ureter and the open-ended catheter was removed.  Over the guidewire a 24-cm, 6-French double-J ureteral stent was then passed, and the wire was removed.  There was excellent curl of the stent, both within the kidney, and in the bladder.  The scope was removed and a 16-French Foley catheter was placed.

 

The patient tolerated the procedure well, and there were no complications.  She was transferred to the recovery room, extubated, awake and alert, and in a satisfactory condition.

 

 

PREOPERATIVE DIAGNOSIS:

 

1.  Stage III pelvic organ prolapse with leading edge of the bulge.

2.  Obstructive defecation, stress incontinence with reduction of the prolapse.

 

POSTOPERATIVE DIAGNOSIS:

 

1.  Stage III pelvic organ prolapse with leading edge of the bulge.

2.  Obstructive defecation, stress incontinence with reduction of the prolapse.

 

OPERATION:

 

Abdominosacral colpopexy with Gynemesh, partial vaginectomy, sigmoid resection, tension-free vaginal tape suburethral sling procedure, and cystourethroscopy.  This portion of dictation will include abdominosacral colpopexy, partial vaginectomy, and tension-free vaginal tape (TVT) sling, and cystoscopy.  The sigmoid resection will be dictated under separate cover by Dr..

 

ANESTHESIA:

 

ANESTHESIOLOGIST:

 

FINDINGS: Revealed complete vaginal prolapse, stage III, absence of the ovaries, no real pelvic adhesions, and normal upper abdominal findings.  Cystoscopy revealed normal efflux of dye from both ureteral orifices and no evidence of perforated sutures.  There was normal urethra that spontaneously opened with filling the bladder to capacity.

 

DESCRIPTION OF PROCEDURE:  Fluids Given Intraoperatively:  3800 cc.  Urine Output:  250 cc.  Estimated Blood Loss:  Approximately 250 cc.

 

The patient was brought to the operating room in stable condition.  After suitable level of general anesthesia was instilled, the patient was placed in dorsal lithotomy position and then prepped and draped in a sterile fashion.  A Foley catheter was placed into the bladder with return of clear urine.  The abdominal wall opening and sigmoid resection will be dictated under separate cover.  Once the sigmoid resection had been performed, a device was then placed into the vagina to expose the elongated vagina which reached all the way back to the sacrum.  There was a total absence of the pubocervical fascia and retrovaginal septum at the top of the vagina.  The parietal peritoneum was opened over the vagina, and the bladder was dissected cephalad.  Similarly, dissection was made posteriorly to enter the rectovaginal space.  A 4 cm portion of the vagina was completely denuded.  Using the autosuture reticulated with Vicryl staples, this was placed over the upper part of the vagina and engaged.  The upper portion of the vagina was then resected.  The reticulum was then released, and the suture line was noted to be intact.  The corners of the suture line were reinforced with interrupted #2-0 PDS suture.  At this point, the Gynemesh was soaked in bacitracin solution.  The anterior leaf of the mesh was then secured to the anterior portion of the vagina in a cervical fashion using interrupted #2-0 PDS suture followed by 3 interrupted Prolene sutures at the edges.  Proceedingly, the posterior leaf of the graft was then placed deep into the retrovaginal space, secured with #0 Prolene suture.  Approximately, 6 sutures were placed.  Care was taken to make sure there were no completely perforated sutures to the vagina.  The 2 leaves of the graft were then secured along the longitudinal axis using a #2-0 PDS suture.  At this point, the completion of the sigmoid resection was performed, and the anastomosis was secured.  Once the anastomosis procedure was completed, we then turned to the presacral area and sacral promontory and incised the peritoneum and fascia over the sacrum.  The presacral ligament was exposed, and 4 interrupted sutures of Prolene were placed.  The graft was then tunneled in the retroperitoneal space to expose the sigmoid colon and then tied down using the 4 sutures placed in the presacral ligament.  The graft was placed without tension.  It was then reperitonealized using the redundant bladder peritoneum using #2-0 PDS suture.  Similarly, the graft at the level of the cuff was recovered and reperitonealized.  The pelvis was then vigorously irrigated, and the abdominal wall closure was then performed as noted in the dictation from Dr..  Once the skin was closed, I then proceeded to the tension-free vaginal tape procedure.  The patient was placed in high lithotomy position.  The suprapubic area was identified in the midline, and approximately 2 cm to the left and the right of midline were demarcated with a marking pen.  This area was then injected with 0.25% Marcaine with epinephrine deep into the subcutaneous tissues using spinal needle.  Approximately, 10 cc were used on either side.  A 1 cm stab incision was made over the previously injected areas.  We then turned from the vaginal portion of the procedure.  The midportion of the urethra was identified using a Foley bulb with a guide.  The vagina over the midurethra area was injected with 0.25% Marcaine with epinephrine until blanching.  A 1.5 cm linear incision was made.  A very minimal dissection was made to the right and left of the incision.  The TVT apparatus was then assembled.  The first arm of the TVT needle was then placed towards the patient's right ipsilateral shoulder.  The Foley with the attached guide was then placed and deviated to the patient's right thigh.  The needle exited through the skin incision of the abdominal wall.  At this point, cystourethroscopy was performed with a 70-degree telescoping.  There was no evidence of perforation of the needle through the bladder.  At this point, the bladder was emptied.  The cystoscope was removed.  Then, the needle with the attached tape and sheath were then pulled to the skin.  The needle was then transected from the tape and sheath and then secured with a hemostat.  The procedure was then repeated on the left side in a similar fashion, again placing the Foley catheter and then deviated the urethra to the patient's left side.  Once the needle was placed and exited through the abdominal wall incision, again, cystourethroscopy was performed, and there was no evidence of perforation noted over the anterior wall and dome of the bladder.  Sterilely, the needle was pulled by incision and transected.  At this point, 2 arms of the tape in the overlying sheath were then adjusted.  A #18 guide was placed between the urethra and the tape, and then the sheath was then removed to leave a 1 cm gap.  The vaginal incision was then closed using interrupted #2-0 Vicryl suture.  It was noted that the buttonhole was made on the patient's right side.  The vagina was then opened over the buttonhole, and a small dissection was performed to allow complete burial of the graft on right edge.