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Cystoscopy and Transplant Stent Removal Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  End-stage renal disease, status post transplant.
2.  Indwelling ureteral stent.

POSTOPERATIVE DIAGNOSES:
1.  End-stage renal disease, status post transplant.
2.  Indwelling ureteral stent.

PROCEDURES PERFORMED:
1.  Cystoscopy.
2.  Removal of transplant stent.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

FINDINGS:
1.  Transplant stent removed intact without difficulty.
2.  Negative cystoscopy.

ESTIMATED BLOOD LOSS:  Minimal.

DRAINS:  None.

COMPLICATIONS:  None.

DISPOSITION:  Stable.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female, status post renal transplant, who presents for stent removal. Risks and benefits of the procedure including bleeding, infection, damage to the urethra, bladder, ureter or kidney, failure to diagnose or treat disease, recurrence of disease or need for further procedures were explained in detail to the patient prior to the procedure. The patient wished to proceed.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room, and after adequate anesthesia, the patient was placed in the dorsal lithotomy position on the operating room table. The genital and perineal regions and urethra were prepped and draped in sterile fashion. A 21 French scope was manipulated easily into the patient's urethra and into the bladder without difficulty. The stent was easily visible on the dome of the bladder and was removed with a flexible grasper. No other foreign bodies or mucosal lesions were seen within the bladder. The bladder was drained and the scope was removed. The patient tolerated the procedure well. There were no complications. The patient was awakened and transported to the postanesthesia care unit in stable condition.

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