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Percutaneous Nephrolithotomy Medical Transcription Op Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left renal calculi.
2.  Left ureteral calculi.
3.  Left calcified indwelling stent.

POSTOPERATIVE DIAGNOSES:
1.  Left renal calculi.
2.  Left ureteral calculi.
3.  Left calcified indwelling stent.

OPERATION PERFORMED:
1.  Left percutaneous nephrolithotomy.
2.  Left ureteral stent exchange.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

SPECIMENS:  Kidney stones.

ESTIMATED BLOOD LOSS:  100 mL.

DRAINS:  A 16-French Foley catheter and 18-French nephrostomy tube.

INDICATIONS:  The patient is a (XX)-year-old male with a history of bilateral kidney stones. The patient had an obstructing left proximal ureteral stone at the proximal ureter and ureteropelvic junction and some calculi in the lower pole of the kidney. He had undergone previous extracorporeal shock-wave lithotripsies and ureteroscopies without success. The patient had an indwelling stent and attempts previously to remove this had been unsuccessful due to calcification of the stent. The patient had a nephrostomy tube placed and is now here for definitive management of his stones with percutaneous nephrolithotripsy.

DESCRIPTION OF OPERATION:  The patient was brought to the procedure room and placed on the table in the supine position. He was given general anesthetic and intubated. He was then placed in the prone position. All pressure points were padded. Through the nephrostomy tube, which was in place, we passed a 0.035 guidewire. This guidewire was then looped as many times as possible from the renal pelvis. At this time, the nephrostomy tube was removed over the wire. I then passed double introducer over this wire, and then once this was in the renal pelvis, I advanced a 0.035 sensor guidewire into the renal pelvis and again curled this as many times as possible. At this time, I passed a NephroMax balloon dilator over the sensor guidewire. This was passed to what I felt was the level of the renal pelvis. This was inflated to 14 cm of water, held for 3 minutes. I then passed the access sheath over the balloon without difficulty.

At this time, I used rigid nephroscope to enter the collecting system. There was no active bleeding noted. At this point, I could see the large impacted stones at the level of the UPJ. A calcified stent was also seen in the renal pelvis, which was calcified along its entire length within the renal pelvis. I then used the ultrasonic lithotriptor to begin ablating the stone. A three-prong grasper was used to grasp the larger and smaller pieces and pull them free. I was able to clear the entire stone after a period of time, down several centimeters of the ureter, which was significantly dilated allowing access to the nephroscope. Once I had access to the ureter, I passed a sensor guidewire down the ureter to the level of the bladder and then removed the previous two wires, which had been placed within the renal pelvis. There were some stones within the lower pole as well, and these were visualized and removed with a three-prong grasper.

There was another calcification, which was in the mid calyceal system. I was able to use the flexible cystoscope, which I passed in this area, and using a Zero Tip Nitinol basket, I was able to basket this and pull this free. I was also able to pass the flexible cystoscope down the ureter and there were no calcifications noted down the ureter. There were also no significant strictures at this point; although, there was significant edema where this stone had been impacted within the ureter. Due to the significant edema of the proximal ureter, I felt it safest to place an indwelling stent. Therefore, over the wire, which was down the ureter, I passed an antegrade 6 x 24 French double-J stent. This could be seen curling in the bladder from below and the renal pelvis above, once the wire was removed. At this point, since there was no bleeding noted, I passed an 18 French Foley catheter. Balloon was filled with 2.5 mL of water. I performed a nephrostogram and this was noted to be in good position within the renal pelvis. The access sheath was then cut away from the nephrostomy tube and removed from the patient. Nephrostomy tube was then sutured to the skin with 2-0 silk. The patient was then transferred to the postop care unit in stable condition.

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