PREOPERATIVE DIAGNOSIS:
Left renal calculi.
POSTOPERATIVE DIAGNOSES:
1. Left renal
calculi.
2. Urethral calculus.
OPERATIONS PERFORMED:
1. Cystoscopy - through
suprapubic sinus.
2. Left ureteral
stent placement.
3. Cystolitholapaxy.
SURGEON: John Doe , MD
ANESTHESIA: General.
DRAINS: None.
SPECIMENS REMOVED: Urethral/bladder
calculus (1 x 2.6 cm).
TUBES: Foley, 24-French.
ESTIMATED BLOOD LOSS: Zero.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the cystoscopy
suite by the OR and anesthesia staff and put on the cystoscopy table. The
patient was gently induced with anesthesia and intubated without difficulty.
The patient was then brought down to the edge of the cystoscopy table and
placed in dorsal lithotomy position. His peritoneum and lower abdomen were
prepped and draped in a sterile fashion. His suprapubic catheter, which was a
24-French catheter, was removed. At this point, a 21-French rigid cystoscope
was passed, with a 30-degree lens, through the suprapubic sinus easily into the
bladder. The bladder was systematically inspected and showed some chronic
inflammatory changes due to chronic indwelling suprapubic tube. His ureteral
orifices were identified bilaterally and were in normal anatomic configuration.
At this point, we followed the trigone down into the
prostatic fossa where the verumontanum was identified. There was also a large
urethral/bladder calculus approximately 1 x 2.6 cm sitting in the prostatic
fossa. On later examination with the 70-degree scope, it was seen that there
was no outside communication of the urethra to the external genitalia, and that
the urethra must have been tied off at some point in the past. Attention was
then turned to the left ureteral orifice. A 0.035 inch Glidewire was attempted
to be passed through the cystoscope into the left ureteral orifice. This was
unsuccessful, as the angle was difficult through the suprapubic sinus. At this
point, an angled Glidewire was tried, which was also unsuccessful. We then
tried an angled, tapered 5-French catheter and this was successful in entering
the ureteral orifice and was passed through this up into the left renal pelvis
under direct visualization and fluoroscopic guidance. Using the push-pull
technique, the angled, tapered catheter was removed over the wire and a 6-French
x 24 cm left ureteral stent was placed. The wire was removed and a curl was
seen in the renal pelvis under fluoroscopic guidance and under direct
visualization in the bladder.
Our attention was then turned to the bladder/urethral
calculus. The rigid cystoscope was removed and a stone crusher was used to
break up the stone into multiple small pieces. The stone was quite easy to
crush. The stone crusher was then removed and an Ellik bulb suction device was
used to attempt to remove these fragments, however, this was unsuccessful due
to the angle. A glass Toomey syringe was then used to barbotage and attempt
removal of the stone fragments. This was also unsuccessful. At this point, we
used a spaghetti suction catheter to suction the stone fragments through the
sheath of the cystoscope and this was successful for the most part. There were
some residual stone fragments, but they were small and insignificant. Minimal
irritation was caused and there were no active bleeders identified. At this
point, the scope was removed and a 24-French Foley catheter was replaced in the
bladder. The patient's urine was clear to pink after the procedure was over and
draining well. The patient was transitioned to the PACU after being
successfully extubated in stable condition.
