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Cystourethroscopy Retrograde Pyelography Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Recurrent dysuria.
2.  Left urolithiasis.

POSTOPERATIVE DIAGNOSES:
1.  Recurrent dysuria, most consistent with interstitial cystitis.
2.  Left urolithiasis.

PROCEDURES PERFORMED:
1.  Cystourethroscopy.
2.  Bilateral retrograde pyelography.
3.  Bladder hydrodilation.
4.  Bladder biopsies.

SURGEON:  John Doe, MD

SEDATION:  General.

DESCRIPTION OF PROCEDURE:  The patient was brought to the cystoscopy suite, and after adequate instillation of general anesthesia, the patient was placed in the lithotomy position. He was prepped and draped in the usual sterile fashion. The patient was examined preprocedure. His physical examination included digital rectal examination with the procurement of expressed prostatic secretions for smear and culture. The patient was again prepped and draped. With the patient adequately prepped and draped, a 21-French cystoscope with a 12-degree lens was inserted through the urethral meatus and advanced under direct visualization with continuous irrigation. The anterior urethra was normal. The posterior urethra revealed changes consistent with benign prostatic hypertrophy; specifically, there is mild enlargement of the lateral lobes, but no significant elevation of the median bar. The supramontanal length is 2-3 cm. The prostatic urethra was visually obstructed. The cystoscope was advanced past an intact bladder neck into the bladder. Urine was obtained for culture and cytology. Bladder volume was approximately 30 mL. The bladder was thoroughly visualized with the 12- and 70-degree lenses. The cystoscopy was unremarkable. The trigone of the bladder was normal. The ureteral orifices were in orthotopic position and effluxed clear urine; specifically, there was clear efflux from the left ureteral orifice. The anterior wall, posterior wall, lateral wall and dome of the bladder were all visualized. The bladder was without significant trabeculation, cellularity and/or diverticula. The bladder was without stone. The bladder mucosa was without lesion; specifically, there was no evidence of bladder tumor, acute/chronic inflammatory stigmata and/or mucosal changes to suggest carcinoma in situ. Once cystoscopy was completed, attention was turned to the trigone. Bilateral retrograde pyelograms were obtained using an 8-French cone-tip catheter. The right collecting system was normal based on retrograde pyelography. The left retrograde pyelogram images a 10 mm calcification in the left lower calix. Once the retrogrades were completed, the decision was made to proceed with lateral hydrodilation and biopsies in an effort to include intersitial cystitis. Standard bladder hydrodilation was performed. Anatomic bladder volume was 800-900 mL. A terminal bloody efflux was appreciated at the time of bladder emptying after bladder hydrodilation. Revisualization of the bladder following bladder hydrodilation revealed diffuse submucosal glomerulation. Hunner ulcers were not appreciated. Due to clinical uncertainty, biopsies were obtained from the posterior wall and lateral walls of the bladder and biopsies were obtained from areas of highest concentration of submucosal glomerulations. The biopsies were sent to Pathology in anatomically labeled container. The biopsy sites were fulgurated with electrocautery. At the completion of the procedure, the biopsy sites were nonbleeding. With the procedure completed, the bladder was emptied and the cystoscope was removed under direct visualization with continuous irrigation. In an effort to optimize the patient's postoperative course, a 16-French Foley catheter was placed into the bladder. It was placed through the urethra into the bladder and placed to gravity drainage after instilling the Foley balloon with 10 mL of sterile water. Drainage from the Foley catheter was blood-tinged; therefore, the patient received 5 mg of Lasix IV push by the anesthesiologist. The patient tolerated the procedure well, was awakened in the operating room, accompanied to the recovery room in stable condition. The estimated blood loss was negligible. He received approximately 700 mL of crystalloid. The procedure was performed without transfusion. The procedure was performed without identifiable complications. Specimens include expressed prostatic secretions, urine culture, urine cytology and bladder biopsies. At the completion of the procedure, there were no dressings. Drains include a 16-French Foley catheter to gravity drainage.