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Prostate Brachytherapy Transcription Sample Report

DATE OF PROCEDURE:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Adenocarcinoma of the prostate.

POSTOPERATIVE DIAGNOSIS:
Adenocarcinoma of the prostate.

PROCEDURE PERFORMED:
Prostate brachytherapy.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia via LMA.

COMPLICATIONS:  None.

DRAINS:  One 18 French Foley catheter per urethra.

INDICATIONS FOR PROCEDURE:  This is a patient with a new diagnosis of adenocarcinoma of the prostate. The patient's initial PSA was 1.6. He had a small irregularity of the left side of his prostate. He had multiple biopsies positive for cancer with a Gleason score of 8. The patient has already had Lupron therapy and external beam radiation treatments. The patient is here today for prostate brachytherapy and informed consent has been obtained.

DESCRIPTION OF PROCEDURE:  The patient was placed on the operating table in the supine position. General anesthesia was administered via LMA. The patient was then placed in the dorsal lithotomy position and the genitalia sterilely prepped and draped in the usual fashion. The prostate ultrasound probe was inserted. The patient had preplanned computer calculations. Palladium 103 radioactive seeds were implanted according to the preplanned computer calculation. A total of 56 seeds through 16 needles, each seed contained 1.04 mCi per seed.

At the end of the procedure, fluoroscopy through C-arm showed good distribution of the seeds throughout the target area. During the procedure, the patient received 400 mg Cipro IV and 6 mg Decadron IV. After recovery from anesthesia, the patient will have CT scan of the pelvis and simulation film of his pelvis for final dose calculation. Target dose will be 10,000 rads. The patient also had received 4500 cGy to his prostate by external beam.

The patient will be discharged with a prescription of Tylenol No. 3, one three times daily as needed, total of 20; Pyridium Plus one twice daily for 10 days; Cardura 1 mg daily for one month with two refills; prednisone 10 mg three times daily for a week; Cipro tablets 500 mg twice daily for five days. Radiation safety instruction was given to the patient and his family. He will return to see Dr. John Doe in two weeks for followup and will see Dr. Jane Doe in four weeks for followup.  The patient tolerated the procedure well and went to the recovery room in satisfactory condition.

Thank you for allowing us to participate in the care of this patient.