PREOPERATIVE DIAGNOSIS: Left renal calculi.
1. Left renal calculi.
2. Urethral calculus.
1. Cystoscopy - through suprapubic sinus.
2. Left ureteral stent placement.
John Doe, MD
SPECIMENS REMOVED: Urethral/bladder calculus (1 x 2.6 cm).
TUBES: Foley, 24-French.
ESTIMATED BLOOD LOSS: Zero.
DESCRIPTION OF OPERATION: The patient was brought to the cystoscopy suite by the OR and anesthesia staff and put on the cystoscopy table. The patient was gently induced with anesthesia and intubated without difficulty. The patient was then brought down to the edge of the cystoscopy table and placed in dorsal lithotomy position. His peritoneum and lower abdomen were prepped and draped in a sterile fashion. His suprapubic catheter, which was a 24-French catheter, was removed. At this point, a 21-French rigid cystoscope was passed, with a 30-degree lens, through the suprapubic sinus easily into the bladder. The bladder was systematically inspected and showed some chronic inflammatory changes due to chronic indwelling suprapubic tube. His ureteral orifices were identified bilaterally and were in normal anatomic configuration.
At this point, we followed the trigone down into the prostatic fossa where the verumontanum was identified. There was also a large urethral/bladder calculus approximately 1 x 2.6 cm sitting in the prostatic fossa. On later examination with the 70-degree scope, it was seen that there was no outside communication of the urethra to the external genitalia, and that the urethra must have been tied off at some point in the past. Attention was then turned to the left ureteral orifice. A 0.035 inch Glidewire was attempted to be passed through the cystoscope into the left ureteral orifice. This was unsuccessful, as the angle was difficult through the suprapubic sinus. At this point, an angled Glidewire was tried, which was also unsuccessful. We then tried an angled, tapered 5-French catheter and this was successful in entering the ureteral orifice and was passed through this up into the left renal pelvis under direct visualization and fluoroscopic guidance. Using the push-pull technique, the angled, tapered catheter was removed over the wire and a 6-French x 24 cm left ureteral stent was placed. The wire was removed and a curl was seen in the renal pelvis under fluoroscopic guidance and under direct visualization in the bladder.
Our attention was then turned to the bladder/urethral calculus. The rigid cystoscope was removed and a stone crusher was used to break up the stone into multiple small pieces. The stone was quite easy to crush. The stone crusher was then removed and an Ellik bulb suction device was used to attempt to remove these fragments, however, this was unsuccessful due to the angle. A glass Toomey syringe was then used to barbotage and attempt removal of the stone fragments. This was also unsuccessful. At this point, we used a spaghetti suction catheter to suction the stone fragments through the sheath of the cystoscope and this was successful for the most part. There were some residual stone fragments, but they were small and insignificant. Minimal irritation was caused and there were no active bleeders identified. At this point, the scope was removed and a 24-French Foley catheter was replaced in the bladder. The patient's urine was clear to pink after the procedure was over and draining well. The patient was transitioned to the PACU after being successfully extubated in stable condition.