Urology Medical Transcription Transcribed Operative Sample Reports for Medical Transcriptionists


DATE OF OPERATION:  MM/DD/YYYY 

PREOPERATIVE DIAGNOSIS:  Right proximal ureteral calculi.

POSTOPERATIVE DIAGNOSIS:  Right proximal ureteral calculi.

OPERATIONS PERFORMED:

1.  Cystoscopy.
2.  Right ureteroscopy.
3.  Laser lithotripsy of ureteral stones and basketing stone fragments.
4.  Placement of double-J stent.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS:  The patient is a (XX)-year-old male with a history of stone disease, who has severe right flank pain and was found to have an obstructing large right proximal ureteral stone. 

DESCRIPTION OF OPERATION:  After induction of general anesthesia, the patient was placed in the lithotomy position.  Genitalia were prepped and draped in the usual sterile fashion.  A #21-French cystoscope was inserted under camera vision.  The urethra was unremarkable.  Prostate revealed early benign BPH, nonobstructive in nature.  The scope was passed into the bladder.  The bladder mucosa was normal throughout.
 
Under fluoroscopic control, a guidewire was placed up the right ureter and bypassed the stone.  This was difficult at first, but the guidewire was eventually manipulated around the stone into the proximal collecting system.  A rigid ureteroscope was then negotiated up the right ureter alongside the guidewire up to the stone, which was at approximately the junction of the upper third and the middle two-thirds of the ureter.  The stone was quite large and occupied the entire lumen of the ureter.
 
Laser lithotripsy was then performed under camera vision.  Using the Holmium laser, the stone was fragmented into multiple fragments, all of which were then individually basketed.  Some of the stones were sent for analysis.  Further ureteroscopy up to the kidney failed to reveal any significant sized fragments.  Therefore, the ureteroscope was removed and a 24 cm length, #6 French diameter double-J stent was negotiated over the guidewire and the guidewire was removed.  The stent was seen curled in good position in the renal pelvis on fluoroscopy and with some redundancy in the bladder on cystoscopy.  The procedure was well tolerated by the patient without complications.  The patient was taken to the recovery room in stable condition.
 
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DATE OF OPERATION:
 
PREOPERATIVE DIAGNOSIS:  Bilateral urolithiasis.
 
POSTOPERATIVE DIAGNOSIS:  Bilateral urolithiasis.
 
OPERATIONS PERFORMED:
 
1.  Cystoscopy.
2.  Right retrograde pyelogram.
3.  Right ureteral stent placement.
4.  Right extracorporeal shock wave lithotripsy.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  Laryngeal mask general.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
ESTIMATED BLOOD LOSS:  Minimal.
 
IV FLUIDS:  2.5 liters crystalloid.
 
SPECIMENS:  None.
 
DRAINS:  A #5-French x 28 cm right double-pigtail ureteral stent and #18-French Foley catheter.
 
COMPLICATIONS:  None. 
 
INDICATIONS:  The patient is a (XX)-year-old white female without prior history of kidney stones.  She underwent parathyroidectomy in the past.  She has recently had intermittent right flank pain and an ultrasound showed mild dilation of the right collecting system with a 12-mm stone.  Smaller stones were noted in the left kidney without any hydronephrosis.  This was confirmed on her KUB showing a 12-mm stone in the right mid kidney and three stones on the left measuring 4-5 mm.  She has had followup testing through Dr. Doe showing a 24-hour urine calcium output of only 90 mg.  Her serum calcium level is normal.
 
DESCRIPTION OF THE PROCEDURE:  The patient was brought to the lithotripsy suite.  After induction of laryngeal mask general anesthesia, she was placed in dorsal lithotomy position.  Perineum and introitus were prepped and draped.  A #22-French rigid cystoscope was passed per urethra with obturator.  The bladder was drained and then inspected with 12- and 70-degree lenses.  She has a central cystocele.  Both orifices appear normal.  Minimal squamous metaplasia in the bladder neck area and no suspicious mucosal changes elsewhere.  No trabeculation noted.  Pollack catheter was threaded into the right ureter and dilute contrast was used to perform segmental pyelogram images on the right.  Distally, multiple pelvic calcifications are lateral to the ureter consistent with phleboliths.  No obvious filling defects seen.  There is mild dilation of the majority of the collecting system above the pelvic brim.  The stone appeared to be free floating within the renal pelvis.
 
Sensor guidewire was threaded up into the kidney.  The Pollack catheter was inserted over the wire and the ureteral length was estimated.  The contrast in the kidney was also allowed to drain to improve visualization of the stone for lithotripsy.  The guidewire was then replaced and the Pollack catheter removed.  A #5-French x 28 cm Polaris double-pigtail stent was then inserted with good pigtail formation on both ends.  Cystoscope was removed and replaced with an #18-French Foley catheter. 
Extracorporeal shock wave lithotripsy was then performed on the right kidney stone.  Shock waves were delivered 120 per minute ungated.  There were no arrhythmias.  Shock waves were gradually increased from energy level setting of 1 to a maximum of 8.  The stone appeared to fragment well.  Periodic AP and oblique fluoroscopy was used.  After 2000 shocks, the patient was awakened, extubated and transported to the recovery room in stable condition.
 

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DATE OF OPERATION: 
 
PREOPERATIVE DIAGNOSES:
1.  Interstitial cystitis.
2.  Urethral stenosis.
 
POSTOPERATIVE DIAGNOSES:
1.  Interstitial cystitis.
2.  Urethral stenosis.
 
OPERATIONS PERFORMED:
1.  Cystoscopy.
2.  Urethral dilation and hydrodilation.
 
SURGEON:  John Doe, MD
 
OPERATIVE FINDINGS:  Urethra was tight at 26-French and dilated with 32-French.  Bladder neck is normal.  Ureteral orifice is normal size, shape and position, effluxing clear bilaterally.  Bladder mucosa is normal.  Bladder capacity is 700 mL under anesthesia.  There is moderate glomerulation consistent with interstitial cystitis at the end of hydrodilation.  Residual urine was 150 mL.
 
INDICATIONS:  A patient with severe symptoms.
 
DESCRIPTION OF OPERATION:  The patient was brought to the cystoscopy suite and placed on the table in lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  A 21 Olympus cystoscope was inserted and the bladder, viewed with 12- and 70-degree lenses.  Bladder was filled by gravity to capacity, emptied and again cystoscopy was performed with findings as above.  Urethra was then calibrated with 32-French.  The patient was taken to the recovery room in stable condition.
 
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PROCEDURES PERFORMED: 
1.  Cystoscopy. 
2.  Bladder biopsy. 
3.  Bilateral retrograde pyelogram. 
4.  Right ureteroscopy with right ureteral stent placement. 

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room, and after adequate anesthesia was placed in the dorsal lithotomy position on the OR table, her genital and perineal regions were prepped and draped in the usual sterile fashion. The 21 French cystoscope was manipulated easily into the patient's urethra, which appeared normal, and into the patient's bladder. The bladder was examined thoroughly. The urine was bloody. No clots were seen in the bladder. The bladder was irrigated clear and no urothelial lesions were seen in the bladder. The left ureteral orifice was effluxing clear urine. The right ureteral orifice was effluxing blood-tinged urine. A 5 French catheter was used to cannulate the left ureteral orifice and dilute contrast was injected, revealing no filling defects and no signs of obstruction in the left collecting system. The catheter was then used to cannulate the right ureteral orifice and contrast was injected revealing no filling defects and no signs of obstruction. The right proximal ureter and right renal pelvis were slightly dilated. I then advanced a guidewire through the catheter up into the right renal pelvis under fluoroscopic guidance and removed the catheter and the cystoscope. I then manipulated the 4 French rigid ureteroscope into the bladder and into the right ureter without difficulty. No ureteral lesions were seen. The urine was bloody in the right renal pelvis. I irrigated the renal pelvis clear and then switched out the rigid ureteroscope for the flexible ureteroscope without difficulty. I examined the renal pelvis and all of the calices. The papilla was prominent in the right lower pole, and the papilla was absent x2 in the right upper pole consistent with papillary necrosis. No other lesions were seen in the renal pelvis. Renal pelvis washings were sent to cytology. The wire was in the correct intraluminal location throughout the length of the ureter. The scope was then withdrawn and a 6 French x 24 cm double-J ureteral stent was placed in the right collecting system under fluoroscopic guidance. I then used the cold cup biopsy forceps to biopsy the cystic changes on the trigone of the bladder. These were most consistent with cystitis cystica; however, due to the patient's hematuria, it was felt prudent to perform biopsy. The Bugbee electrode was used to obtain excellent hemostasis. The bladder was not perforated. The bladder was drained and the scope was removed. The patient tolerated the procedure well. There were no complications. The patient was awakened and transported to the postanesthesia care unit in stable condition.

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DATE OF OPERATION:
 
PREOPERATIVE DIAGNOSES:
1.  Benign prostatic hypertrophy with obstruction and retention.
2.  Prostate cancer.
 
POSTOPERATIVE DIAGNOSES:
1.  Benign prostatic hypertrophy with obstruction and retention.
2.  Prostate cancer.
 
OPERATION PERFORMED:  Cystoscopy and green light laser transurethral resection of prostate.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  Laryngeal mask airway and MAC.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
INDICATIONS:  The patient is a (XX)-year-old gentleman with prostate cancer and significant trilobar hypertrophy who has had a prostate over 100 grams and has been managed with intermittent hormone therapy.  The patient recently underwent further evaluation for treatment of his prostate cancer and was deemed not a candidate for brachytherapy given his trilobar hypertrophy.  His prostate was re-evaluated by Dr. Doe and felt to have a 42-gram prostate with significant trilobar hypertrophy.  He wished to undergo a green light TURP after extensive counseling and discussion prior to his brachytherapy.  He understands the risks and benefits of the procedure including bleeding, need for re-treatment and dysuria and incontinence.
 
DESCRIPTION OF OPERATION:  After the patient was given anesthesia, he was prepped and draped in the dorsal lithotomy position.  A #21-French rigid cystourethroscope was advanced into his urethra.  He was found to have significant trilobar hypertrophy.  His bladder was also trabeculated with some debris in the bladder.
 
The patient had a continuous flow cystoscope attachment placed.  Using the green light laser fiber, the patient had ablation of the median lobe initially.  The median lobe was ablated with care taken not to ablate into the bladder.  Then, the lateral lobes were ablated to the level of the verumontanum.  Care was taken to not resect beyond the verumontanum.  The anterior wall was also then resected as it coapted into the field.  The patient had a good channel.  The cystoscope was passed without any difficulty and there was no bleeding.
 
The patient then had his bladder drained and had a #20-French 3-way soft catheter introduced into his bladder without any difficulty.  Urine was clear.  In the balloon, 30 mL of water was placed.
 
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DATE OF OPERATION: 
 
PREOPERATIVE DIAGNOSIS:  Carcinoma of the prostate.
 
POSTOPERATIVE DIAGNOSIS:  Carcinoma of the prostate.
 
OPERATION PERFORMED:  Transperineal cryoablation of the prostate and suprapubic tube placement.
 
SURGEON:  John Doe, MD
 
ANESTHESIA:  Spinal.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
OPERATION IN DETAIL:  The patient was brought to the operating room and placed on the operating room table in the supine position.  After induction of adequate spinal anesthesia, the patient was placed in the dorsal lithotomy position.  His lower abdomen, genitalia and perineum were prepped and draped in the usual sterile manner.  A Foley catheter was passed into the bladder.  Ultrasound was then performed to evaluate the prostate for cryoprobe placement.  Once the prostate had been mapped out and the computer utilized to guide probe placement, 6 cryoprobes were placed as well as temperature probes in the area of the external sphincter, the apex, the Denonvilliers fascia and the right and left neurovascular bundles.  Flexible cystoscopy was performed to confirm the absence of any probes within the bladder.  The placement of the external sphincter probe was then confirmed via both ultrasound and direct inspection of the urethra around the verumontanum.  Once probe placement was deemed satisfactory, the bladder was filled and a spinal needle was used to localize the bladder.  The cystoscope was then removed after placement of a 0.038 wire through its working channel to facilitate urethral warmer placement.  A suprapubic tube was then placed with a 16-French catheter being utilized.  The bladder was decompressed and the catheter plugged.  The urethral warmer was then passed over the wire into the bladder without any difficulty.  The wire was removed and the freezing process begun.  A double freeze-thaw cycle was performed with all temperatures being monitored closely to prevent injury.  Throughout the procedure, the urethral warmer was slid back and forth to ensure that there was no evidence of any freezing of the urethra.  An excellent freeze was obtained as monitored both ultrasonographically and through the monitoring probes.  They were removed without any difficulty.  Rectal examination was performed, which revealed a perfectly intact rectal mucosa.  Manual pressure was applied to the perineal wounds, which were then dressed with a gauze loaded with bacitracin ointment.  A dry sterile dressing was placed around the suprapubic tube.  The patient tolerated the procedure well and was transported in stable condition to recovery.

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