Urology Transcription Operative Samples for Medical Transcriptionists:
PROCEDURES PERFORMED: Cystoscopy, left ureteroscopy, left retrograde pyelogram, left ureteral stent change.
PROCEDURE IN DETAIL: The patient was taken to the operating room and, after adequate anesthesia, was placed in the dorsal lithotomy position on the OR table. The patient's genital and perineal regions were prepped and draped in sterile fashion. The 21-French cystoscope was manipulated easily through the patient's urethra, which appeared normal, into the bladder. There were no foreign bodies or mucosal lesions seen in the bladder except for the stent effluxing from the left ureteral orifice. The tip of the stent was grasped and removed to the level of the urethral meatus under fluoroscopic guidance. A guidewire was then passed through the stent and this was manipulated up to the level of the UPJ without difficulty. With some difficulty, I was able to manipulate the tip of the wire through the strictured area, which appeared to be approximately 1 cm into the renal pelvis. I then manipulated a 5 French Pollack catheter over the wire into the left renal pelvis. Left renal pelvis fluid was obtained and sent to pathology for cytology. I did inject some contrast confirming the presence of tip of the catheter in the renal pelvis. I then performed pull-out retrograde pyelogram, and this revealed a strictured area approximately 1 cm at the ureteropelvic junction. There was also some kinking at the UPJ. No filling defects were seen in the renal pelvis and no other abnormalities were seen in the ureter. I then manipulated the wire back into the renal pelvis and manipulated the flexible ureteroscope over the guidewire into the renal pelvis. I examined the renal pelvis and no mucosal abnormalities or foreign bodies were seen in the renal pelvis. I then withdrew the scope slowly. The strictured area was narrow; however, no worrisome urothelial changes were seen. The remainder of the ureteroscopic exam was normal. Prior to removing the second guidewire, I did manipulate a fresh 6 French x 22 cm left double-J ureteral stent by Seldinger technique into the left collecting system with the tip of the stent in the left renal pelvis. I drained the bladder and removed the scope. I taped the external tether of the stent to the patients' abdomen. The patient tolerated the procedure well. There were no complications. The patient was awakened and transported to the postanesthesia care unit in stable condition.
PROCEDURES PERFORMED: Cystoscopy, urethral dilatation and calibration, bilateral retrograde pyelogram.
PROCEDURE IN DETAIL: The patient was taken to the operating room. After adequate anesthesia, the patient was placed in the dorsal lithotomy position on the OR table. The patient's genital and perineal regions were prepped and draped in a sterile fashion. The 21-French cystoscope with a 25-degree lens was manipulated easily through the patient's urethra, which appeared normal, to the level of the bulbar urethra where a tight stricture was encountered. It was approximately less than 10 French in diameter. I passed a guidewire through this stricture, I was unable to manipulate the cystoscope through the stricture. I then, using direct visualization with the scope, placed a filiform and followers to dilate the stricture from 8 French to 24 French without difficulty. I was then able to manipulate the scope through the prostatic urethra, which appeared normal, into the bladder. The bladder was moderately trabeculated. There were no foreign bodies or mucosal lesions seen in the bladder. Bilateral ureteral orifices were effluxing clear urine. The left ureteral orifice was cannulated easily and dilute contrast was injected revealing no filling defects and no signs of obstruction. With some difficulty, I was able to cannulate the right ureteral orifice, which was at a difficult angle. Dilute contrast was also injected revealing no filling defects and signs of obstruction in the right collecting system. Both collecting systems drained normally after draining the bladder. The scope was then removed and an 18-French Foley catheter was placed. The balloon was inflated to 7 mL and a leg bag was placed. There was no evidence of active bleeding. The patient tolerated the procedure well. There were no complications. The patient was awakened and transferred to postanesthesia care in stable condition.
OPERATION PERFORMED: Right hand-assisted laparoscopic nephrectomy.
OPERATION IN DETAIL: The patient was taken to the operating room. After adequate anesthesia was placed in the modified left flank position, the patient underwent laparoscopic cholecystectomy. Once this was completed, we then proceeded with hand-assisted laparoscopic nephrectomy. The umbilical port was extended to make a GelPort. This was done by extending the incision around the umbilicus for approximately 6 cm. The GelPort was then placed. The camera was then used to place a 12 mm port in the right upper quadrant and the existing right lower quadrant port was used as well. The anterior abdominal contents were evaluated. The patient was status post cholecystectomy. No other intra-abdominal abnormalities were seen. The line of Toldt was incised and the colon was reflected medially. This exposed the right kidney within Gerota's fascia. The peritoneum was incised medially over Gerota's fascia and the bowel was again retracted medially. Using a combination of sharp and blunt dissection using the Harmonic scalpel and the Probe Plus, the plane between the lateral abdominal wall and the kidney was developed. The ureter was identified inferomedially and was doubly clipped and then divided. The stent was removed from the distal ureter. The dissection was proceeded medially and the renal pedicle was identified. The renal vessels were ligated and divided using the Endo-GIA device with the vascular staples. The remaining attachments of the kidney to the superior portion of the abdominal wall and adrenal gland were then divided using the Harmonic scalpel. The kidney was removed and sent to pathology. The bed of the resection was irrigated and excellent hemostasis was achieved. No bowel injuries were apparent. All sponges were removed from the abdomen. The camera was used to remove the ports under direct vision. Vicryl sutures were used to close the fascial incisions of the laparoscopic ports. The GelPort was then closed with interrupted #1 Vicryl sutures. The skin edges were closed with subcuticular sutures. Benzoin and Steri-Strips were placed as well as Tegaderm dressings. The instrument, sponge and needle counts were correct. The patient tolerated the procedure well. There were no complications. He was awakened and transported to the postanesthesia care unit in stable condition.
OPERATION PERFORMED: Left radical nephrectomy.
OPERATION IN DETAIL: The patient was taken to the operating room and placed in the supine position. After induction of anesthesia, the patient was placed in the supine position with a roll under his left side. The table was flexed. NG tube and a Foley catheter were placed and then the entire abdomen was cleaned, prepped and draped to a sterile field. Scalpel was used to make a left-sided subcostal incision. We carried it from the tip of the 12th rib over towards the midline. This was carried down through the subcutaneous tissues. We used cautery to incise the external oblique, internal oblique and transversus layers. The peritoneum was sharply entered. We opened up the peritoneum in both directions. Self-retaining retractor was placed. We started by reflecting over the left colon. We easily identified the peritoneal line and we incised the colon to take it down. We then went up around the spleen and took down the attachments between the colon and the spleen, which allowed us to bring the colon medial. Once we did this, we had good exposure of the kidney. We found the tail of the Gerota and started working behind the kidney. Using cautery and the Gyrus cautery unit, we incised the posterior attachments and freed up the entire kidney posteriorly. We then took the tail of Gerota, divided it into several packets and cauterized this and divided it. We identified the ureter. We isolated it and we put two clips proximal and two distal and divided in between. Using the ureter as our guide, we continued to work up medial. We were able to pull the colon over medial and expose the hilum of the kidney. We cleaned off the area over the renal vein and renal artery. The renal artery was a single large vessel. We isolated the renal vein first with a vessel loop to pull it away and then we put two heavy silk ties around the renal artery. It was tied off. A third tie was placed close to the kidney and the artery was divided. We then placed two large silk ties on the proximal part of the renal vein, one near the kidney and cut in between. With the hilum divided, we then worked lateral. We took out the lateral attachments and worked up around the spleen. We took down the Gerota attachments using the Gyrus cautery device, coming up around towards the upper pole of the kidney. The dissection around the adrenal was left for Dr. Doe. Once we freed up the kidney except for the adrenal gland, Dr. Doe scrubbed in and dissected around the adrenal gland to remove it intact. Please see his note for details. Once the kidney and the adrenal were removed, we irrigated the entire renal bed with sterile water. We checked for bleeding around the hilum and all other areas and no bleeding was noted. We checked the spleen and there was no laceration. The pancreas was also not injured. We then allowed the colon to come back into the renal fossa and allowed the small bowel to go back to its normal position. We brought the omentum over and began closure. All the laps were removed. At this point, closure was begun. We closed the posterior layer with a running Vicryl heavy suture. A looped Maxon x2 was used to close the external oblique fascia in two directions. The wound was copiously irrigated and an On-Q pump was placed through the deep layers. Subcuticular chromic was used to close the subcutaneous tissue and then staples were placed on the skin. Sterile dressing was applied. The patient was taken to recovery in stable condition. Blood loss was 50 mL. The patient tolerated the procedure well.
PROCEDURES PERFORMED: Right ureteroscopy with lithoclast and Holmium laser lithotripsy, cystoscopy with removal of multiple bladder stones with right retrograde pyelogram and placement of right double-J stent.
PROCEDURE IN DETAIL: The patient was taken to the operating room and placed in the supine position. After induction of anesthesia, the patient was placed in dorsal lithotomy, and all pressure points were carefully padded. His entire perineum was cleaned, prepped, and draped to a sterile field. The rigid cystoscope was introduced atraumatically into the bladder. The urethra and prostate were normal. The bladder was visualized. It showed no stones in the bladder but there was a big raised area over the right ureteral orifice with the stone inside. On fluoro, we could see the very large stone in the distal right ureter and what appeared to be an ureterocele. At this point, we did a retrograde with contrast. We could outline the ureter, which appeared to be normal up to the collecting system. We then advanced the central wire around the large stone up the right ureter. Next, we used 6, 8, and 10 dilators to dilate up the distal ureter to 10 French. We then exchanged the ureteroscope and went up with the ureter. Just inside the ureteral orifice, we encountered a very large 1.8 cm tan appearing stone. This stone was quite hard. We started with the Holmium laser. Using the Holmium laser, we did lithotripsy and continued to fragment the stone. Because of its large size, we had to work continuously over the stone, being careful to stay away from the wire and the mucosa. The stone broke up well with the Holmium laser. We continued to fragment until we had vaporized at least half the stone. At this point, when we thinned it out, we removed the Holmium laser and went to the lithoclast. Using the lithoclast device, we were able to put it up against the stone and fragment the stone into multiple pieces. We continued working with the lithoclast until it was broken up into many pieces. We then used a three-pronged grasper to pull out the pieces and they were left in the bladder. We went back and forth pulling the pieces out and dropping them in the bladder. Once this was done, we went back and there was still one large piece. We used the lithoclast again to break it up into four pieces. Once these four pieces were removed with the ureteroscope, we could go back up, this time above where the stone was, and the rest of the ureter appeared normal. There was only dust remaining and no large fragments. We pulled back through. We could see no evidence of extravasation. There was no significant bleeding and the ureteroscope was removed. We advanced the ureteral catheter to repeat a retrograde to confirm placement and we put a cystoscope in and ran a 6 x 28 double-J stent over the wire, good coil in the renal pelvis, and good coil in the bladder. At this point, we used the cystoscope to go back in and remove multiple fragments from the bladder, which were all removed and sent off to pathology. Once the bladder was completely removed of all the small stone fragments, we went back in and saw no remaining fragments and the bladder was emptied. The patient was awakened and taken to the recovery room in stable condition and tolerated the procedure well.
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