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Cystoscopy Stone Extraction with Holmium Laser Lithotripsy Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left ureteral stone.

POSTOPERATIVE DIAGNOSIS:
Left ureteral stone.

PROCEDURES PERFORMED:
1.  Cystoscopy.
2.  Left ureteroscopic stone extraction with holmium laser lithotripsy and stent change.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General inhalation.

FINDINGS:  An 8 mm proximal left ureteral stone.

SPECIMENS:  Ureteral stone fragments.

DRAINS:  6 French x 26 cm left double-J ureteral stent.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

DISPOSITION:  Stable.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male with obstructing left ureteral stone, status post stent placement last week. The patient has had intractable pain, nausea, and vomiting. We were unable to discharge him secondary to this. The patient presents for ureteroscopic stone management. The risks and benefits of the procedure, including but not limited to bleeding, infection, damage to the urethra, bladder, ureters, kidneys, failure to diagnose and treat all disease, recurrence of disease, need for further procedures were explained to the patient prior to the procedure, and the patient wished to proceed.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room, and after adequate anesthesia, he was placed in the dorsal lithotomy position on the OR table. The patient’s genital and perineal regions were prepped and draped in the usual sterile fashion. The 21 French cystoscope was manipulated easily through the patient's urethra, which appeared normal, into the bladder. The stent was seen effluxing from the left ureteral orifice, and the end of the stent was removed to the level of the urethral meatus.

A guidewire was then advanced through the stent and passed easily up into the left renal pelvis under fluoroscopic guidance. The stent was then removed. The cystoscope was removed, and a 4 French rigid ureteroscope was then manipulated into the bladder and into the left ureter without difficulty. It was manipulated to the level of the stone without difficulty. A 500 micron laser fiber was then placed, setting of 8 joules, was used to fragment the stone. A Segura mini-basket was then used to remove the fragments from the ureter. The wire was in the correct intraluminal location throughout the length of the ureter. The ureter was examined from the ureterovesical junction to the renal pelvis. No visible stone fragments were seen. The ureter was not perforated or traumatized by the procedure.

The ureteroscope was then withdrawn, and a fresh 6 French x 26 cm double-J ureteral stent was placed by Seldinger technique without difficulty. The wire was removed with the stent in good position. The bladder was drained. The scope was removed. The external stent tether was taped to the patient's penis in a nonconstrictive fashion. The patient tolerated the procedure well. There were no complications. The patient was awakened and transported to the postanesthesia care unit in stable condition.