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Cystourethroscopy Hydrodistention Transcription Sample

DATE OF PROCEDURE:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Pelvic pain, rule out interstitial cystitis and urethral syndrome.

POSTOPERATIVE DIAGNOSIS:
Interstitial cystitis and urethral syndrome.

PROCEDURES PERFORMED:
1.  Cystourethroscopy.
2.  Hydrodistention of the bladder.
3.  Urethral dilatation.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIA:
General LMA.

COMPLICATIONS:
None.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old female with a history of significant bladder pain and pelvic pain, of unclear etiology. Upon examination in the office, the patient was noted to have an exquisitely tender bladder and urethra and the question of interstitial cystitis was raised. The patient has had a history of a lot of irritative voiding symptoms as well. A cysto hydrodistention and urethral dilatation was recommended. Alternative treatments including the risks, benefits, and expected outcome of each were discussed in detail with the patient, and the patient desired to proceed with the planned operation.

DESCRIPTION OF PROCEDURE AND FINDINGS:
After thorough preoperative evaluation, the patient was taken to the cysto room and placed in the supine position on the cysto table. A general LMA anesthesia was administered. The patient was placed in the dorsal lithotomy position, and the external genitalia and perineum scrubbed with povidone-iodine scrub solution followed by sterile draping with towel and drapes in the usual fashion.

The 20-French cystoscope sheath and 30-degree lens with video camera was advanced through the urethra and into the bladder. The urethra showed evidence of inflammatory polyps at the bladder neck but was otherwise normal. The bladder was drained of any residual urine and urine for cytology obtained. The bladder was carefully examined. There was no evidence of neoplasm, stones, or other abnormalities. Both ureteral orifices were intact with clear efflux of urine.

The bladder was then hydrodistended at 80 cm of water pressure for 5 minutes, drained, and then re-examined. Upon re-examination, the final effluent was noted to be pink and the bladder capacity was 800 mL. Upon re-examination of the bladder, there were multiple glomerulations noted throughout the bladder wall suggestive of intersitial cystitis.

After completion of the inspection of the bladder, the bladder was left partially full and cystoscope removed. The urethra was then sequentially dilated with Walther dilators from 24 to 36 French with moderate difficulty. A small amount of bleeding was noted from the urethra after completion of the urethral dilatation.

At this point, the bladder was eventually drained of any residual urine and dilator removed. The patient was taken out of the dorsal lithotomy position and returned to postanesthesia recovery room in stable condition.