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Cystoscopy Ureteroscopy Retrograde Pyelogram Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left proximal ureteral stone.

POSTOPERATIVE DIAGNOSIS:
Left proximal ureteral stone.

OPERATION PERFORMED:
1.  Cystoscopy with left ureteroscopy.
2.  Left retrograde pyelogram.
3.  Left stent placement.

SURGEON:  John Doe, MD

ANESTHESIA:
General.

COMPLICATIONS:
None.

SPECIMEN:
Included urine for culture.

INDICATION FOR PROCEDURE:
The patient is a (XX)-year-old female who was recently seen in-house for left renal colic from a 4 to 5 mm left proximal ureteral stone.  She was initially given a trial of conservative therapy but continued to have symptomatic pain from the stone.  For that reason, it was decided to go ahead and intervene for her symptoms.  The patient has been made aware of the potential risks, benefits, complications and alternatives to undergoing cystoscopy with left ureteroscopy and possible stone extraction, as well as left stent placement.

DESCRIPTION OF PROCEDURE:
The patient was correctly identified and informed consent was obtained.  She was brought to the operating room where, once sufficient anesthesia had been administered, she was prepped and draped in the lithotomy position.

A 21-French rigid cystoscope was passed to the bladder using the obturator.  The bladder was drained and urine was obtained for culture and sensitivity.  A 12-degree lens was then used to perform cystoscopy.  The bladder was unremarkable in appearance.  The left ureteral orifice was identified and was intubated with a 0.038 guidewire.  This was advanced up the ureter under fluoroscopy until a coil was noted in the renal pelvis.  Secondary to tight ureteral opening, the distal ureter was calibrated with a 12-French Nottingham dilator.  At that point, a rigid ureteroscope was passed into the bladder and into the distal ureter without difficulty.  The ureteroscope was advanced up the ureter under direct vision, up to its full length.  Advancement of the rigid ureteroscope as far as it would go did not demonstrate any evidence of stone in that part of the ureter.

At that point, the rigid ureteroscope was removed.  A second guidewire was placed using a dual-lumen ureteral catheter.  A ureteral access sheath was then placed over one of those wires using Seldinger technique.  At that point, a flexible ureteroscope was advanced up the ureteral access sheath into the proximal part of the ureter.  However, secondary to a malfunctioning ureteroscope, which would not deflect, proximal ureteroscopy could not be performed.  Rather than risk injury to the ureter, the ureteroscope and access sheath were removed.

Retrograde pyelogram was performed at that time.  The remaining wire was back-loaded over the cystoscope and a 6 x 22 French was initially attempted to be placed in the left kidney.  However, after placement of the stent, it did appear that it was somewhat short; as such, a grasper was used to remove the stent and this was replaced for a 6 x 24 cm double-J stent.  This was advanced into the kidney without difficulty.  Direct vision confirmed good distal coil in the bladder.  The bladder itself was drained and the scope removed.  Anesthesia was reversed and the patient was taken to the recovery room in satisfactory condition.

DISPOSITION:  The patient is to be discharged home.  Prescription for Levaquin x5 days and Pyridium as needed was given.  We will have her push oral fluids at home and strain urine.  If she has not captured a stone in 2 to 3 weeks, we will repeat upper tract imaging.  Based on stone location at that time, she may be a candidate for ESWL versus definitive ureteroscopy.