Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.

PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:, Less than 10 cc.,INDICATIONS: ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time. The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:, The patient was consented and seen in the preoperative suite. She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation. She was prepped and draped in the normal sterile fashion. Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine. A bimanual exam was done, was performed by Dr. X and Dr. Z. The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage. The cervix and vagina were grossly normal with no obvious masses or deformities. A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm. The cervix was sterilely dilated with Hank dilator and then Hagar dilator. At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously. The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus. Under direct visualization, the ostia were within normal limits. The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps. The hyperplastic tissue did not appear to have calcification or other abnormalities. There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature. The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance. Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting. The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation. A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac. There was a normal consistency of the cervix and the normal step-off. The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum. The cervix was found to be hemostatic. The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room. The patient will be sent home once stable from anesthesia. She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings. The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin. The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks. The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.

abnormal uterine bleeding
cervix
d&c
delivery
dilation and curettage
endometrial
endometrial curettings
hysteroscopy
spontaneous vaginal delivery
surgery
uterine
uterine bleeding
vaginal
vaginal delivery


Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.

PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Hypermenorrhea.,3. Secondary anemia.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm. The cervix is patulous and nulliparous without lesions. Adnexal examination was negative for masses.,PROCEDURE: ,The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum. The uterus was sounded to a depth of 11 cm. The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar. The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera. The endometrial cavity was distended with fluids and the cavity visualized. Multiple irregular areas of fibroid degeneration were noted throughout the cavity. The coronal areas were visualized bilaterally with corresponding tubal ostia. A moderate amount of proliferative appearing endometrium was noted. There were no direct intraluminal lesions seen. The patient tolerated the procedure well. Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis. The instrument was removed from the vaginal vault. The patient was sent to recovery area in satisfactory postoperative condition.

anemia
dilatation and curettage
endometrial cavity
enlarged fibroid uterus
fibroid
hypermenorrhea
hysteroscopy
surgery
uterus


Cystourethroscopy and tTransurethral resection of prostate (TURP). Urinary retention and benign prostate hypertrophy. This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.

PREOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA:, Spinal.,RESECTION TIME:, Less than one hour.,INDICATION FOR PROCEDURE: ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE: PROCEDURE: , Informed written consent was obtained. The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position. She was sterilely prepped and draped in normal fashion. A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder. The bladder was visualized in all quadrants, no bladder tumors or stones were noted. Ureteral orifices were visualized and did appear to be near the enlarged median lobe. Prostate showed trilobar prostatic enlargement. There were some cellules and tuberculations noted. The visual obturator was removed. The resectoscope was then inserted utilizing the #26 French resectoscope loop. Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers. Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum. Ureteral orifices were kept out of harm's way throughout the case. Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion. Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way. The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed. Open prostatic fossa was noted. All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated. Clear return was noted. The patient was then hooked up to better irrigation. The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN: ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.

benign prostate hypertrophy
bladder
cystourethroscopy
enlarged
hypertrophy
obstructive voiding symptoms
prostate
prostate hypertrophy
resection
resectoscope
surgery
transurethral resection of prostate
turp
ureteral orifices
urinary
urinary retention


Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.

PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Pelvic pain.,3. Infertility.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Infertility.,3. Pelvic pain.,4. Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy.,3. Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile. The cervix is nulliparous without lesions. Adnexal examination was negative for masses.,PROCEDURE: ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum. Uterus sounded to a depth of 10.5 cm. Endocervical canal was progressively dilated with Hanks dilators to #20-French. A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis. A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air. A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity. The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted. The laparoscope was then inserted through the trocar with visualization of the pelvic contents. In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas. The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria. The ovaries also appeared normal bilaterally. The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area. An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still. Both fallopian tubes apparently were blocked. The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum. The patient tolerated the procedure well. Instruments were removed from the vaginal vault and the abdomen. Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures. Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.

curettage
dilatation and curettage
endocervical
enlarged fibroid uterus
fallopian tubes
fibroid uterus
indigo carmine
indigo carmine dye
infertility
laparoscopy
pelvic
pelvic pain
peritoneal cavity
surgery
tubal occlusion
uterine
uterus
uterus infertility


Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.

PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Hypermenorrhea.,3. Desire for future fertility.,4. Failed conservative medical therapy.,5. Possible adenomyosis.,6. Left hydrosalpinx.,7. Suspicion for endometriosis.,PROCEDURES PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:, None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion. This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living. Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996. The cyst was not diagnosed as an endometrioma. The patient does desire future fertility; however, would like a definitive diagnosis. Conservative medical therapy was offered i.e. Lupron or repeat oral contraceptives, but declined.,FINDINGS:, Bimanual exam reveals a small retroverted uterus which is easily mobile. There were no adnexal masses. The cervix was normal on palpation. A fibrotic band was noted at the internal os during dilation. On laparoscopic exam, the uterus was found to be small with mild spongy texture. On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis. The left ovary was grossly normal. The left fallopian tube had a mild hydrosalpinx present. The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis. The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac. The liver appeared grossly normal. There were no obvious pelvic adhesions. The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE: ,The patient was seen in the preop suite. History was reviewed and all questions were answered. The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube. She was placed in a dorsal lithotomy position in Allen stirrups. She was prepped and draped in the normal sterile fashion. Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine. A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted. A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum. There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible. A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen. An infraumbilical incision was made using skin scalpel. The Veress needle was placed and CO2 was insufflated. It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed. A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure. The #12 port was placed and the laparoscope was inserted. Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position. The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette. A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation. This procedure was performed under direct laparoscopic visualization. Laparoscopic evaluation of the pelvis was performed and the above findings noted. A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization. A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization. The manipulator was then removed and the Harmonic scalpel was placed through the #5 port. The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament. The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis. There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment. The Harmonic scalpel was removed from the abdomen as was the #5 port. The incision was internally found to be hemostatic. The laparoscope was then removed from the abdomen. The abdomen was desufflated. The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen. The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic. The weighted speculum was then removed. The patient taken out of dorsal lithotomy position. She was recovered from general anesthesia and taken to the postoperative suite for complete recovery. The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology. Her family was notified of the findings. She will be instructed not to have intercourse or use tampons or douche for the next two weeks. The patient will be sent home with a prescription for Darvocet for pain.


Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP).

PREOPERATIVE DIAGNOSES:,1. Benign prostatic hypertrophy.,2. Urinary retention.,POSTOPERATIVE DIAGNOSES:,1. Benign prostatic hypertrophy.,2. Urinary retention.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA: ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS: ,150 cc.,DISPOSITION: ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe. Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder. Cystoscopy performed with the above findings. Cystoscope was removed. A #27 French resectoscope with a #26 cutting loop was inserted into the bladder. Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed. ________ irrigator was used to evacuate the bladder of prostatic chips. Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop. Any obvious bleeding from the prostatic fossa was controlled with electrocautery. Resectoscope was removed. A #24 French three-way Foley catheter inserted into the urethra and into the bladder. Bladder was irrigated and connected to three-way irrigation. The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.

benign prostatic hypertrophy
bladder
bph
cystoscopy
cystourethroscopy
foley catheter
surgery
transurethral resection of prostate
turp
urinary retention


Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration. Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.

PREOPERATIVE DIAGNOSIS: ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1. Urinary hesitancy and weak stream.,2. Urethral narrowing.,3. Mild posterior wall erythema.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Urethral dilation.,3. Bladder biopsy and fulguration.,ANESTHESIA: ,General.,SPECIMEN: ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:, Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French. A midureteral polyp was noted. Cystoscopy revealed multiple cellules and mild trabeculation of the bladder. Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa. No obvious raised bladder tumor was noted. No foreign bodies were noted. The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope. Cystoscopy was performed in its entirety with the above findings. The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area. The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined. No evidence of active bleeding noted. The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks. She is given prescription for Levaquin and Pyridium and given discharge instructions.

biopsy
bladder
bladder biopsy
cystoscope
cystoscopy
cystourethroscopy
fulguration
surgery
urethral
urethral dilation
weak stream


Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.

PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.

barbotage
cystoscope
cystoscopy
flank pain
hydronephrosis
renal pelvis
retrograde
surgery
ureteral
ureteropyelogram
ureterorenoscopy
urine
urine cytology


Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.

PREOPERATIVE DIAGNOSES:,1. Right renal mass.,2. Hematuria.,POSTOPERATIVE DIAGNOSES:,1. Right renal mass.,2. Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Right retrograde pyelogram.,3. Right ureteral pyeloscopy.,4. Right renal biopsy.,5. Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:, The patient is a 74-year-old male who was initially seen in the office with hematuria. He was then brought to the hospital for other medical problems and found to still have hematuria. He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position. He was given IV sedation and placed in dorsal lithotomy position. He was then prepped and draped in the standard fashion. A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder. The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder. There were no masses or any other abnormalities noted other than the tuberculation. Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice. A retrograde pyelogram was performed. Upon visualization, there was no visualization of the upper collecting system on the right side. At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed. The bladder was drained and the cystoscope was removed. The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire. The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities. The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire. The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance. The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter. The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction. The wire was then again passed through the flexible scope and the flexible scope was removed. A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation. The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system. Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system. The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass. Once this was done, the wire was left in place and the ureteroscope was removed. The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis. The stent was noted to be clear within the right renal pelvis as well as in the bladder. The bladder was drained and the cystoscope was removed. The patient tolerated the procedure well. He will be transferred to the recovery room and back to his room. It has been discussed with his primary physician that the patient will likely need a nephrectomy. He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.

amplatz wire
bladder
cystoscope
cystourethroscopy
double-j
flexible scope
hematuria
papillary mass
pyelogram
renal
renal biopsy
renal mass
renal pelvis
retrograde
retrograde pyelogram
surgery
ureteral
ureteral orifice
ureteral pyeloscopy
ureteral stent
ureteral stent placement
ureteropelvic junction
ureteropelvic junction obstruction
ureteroscope


Cystoscopy & Visual urethrotomy procedure

CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:, The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia. A Storz urethrotome sheath was inserted into the urethra under direct vision. Visualization revealed a stricture in the bulbous urethra. This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder. Visualization revealed no other lesions in the bulbous or membranous urethra. Prostatic urethra was normal for age. No foreign bodies, tumors or stones were seen within the bladder. Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.

: thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. all names and dates have beenchanged (or removed) to keep confidentiality. any resemblance of any type of name or date orplace or anything else to real world is purely incidental.


Cystoscopy. Transurethral resection of the prostate.

PREOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,PROCEDURES:,1. Cystoscopy.,2. Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer. His history dates back to 2003 when he had a non-muscle invasive bladder cancer. He had multiple cystoscopies and followups since that time with no evidence of recurrence. However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ. Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities. I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites. We elected to allow his bladder to recover before starting the BCG. We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter. I repeated a cystoscopy in the office with findings of a high bladder neck and BPH. After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms. There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion. A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described. We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds. Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck. The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock. Hemostasis was achieved, and then a similar procedure performed in the right side. We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis. Chips were removed with Ellik evacuator. There was no bleeding at the conclusion of the procedure, and the resectoscope was removed. A #24 French three-way Foley catheter was placed with efflux of clear irrigant. The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.

acmi panendoscope
benign prostatic hypertrophy
bladder
bladder neck
carcinoma
cystoscopy
foley catheter
surgery
transitional cell carcinoma
transurethral resection of the prostate
turp
urinary bladder
van buren sounds


PREOPERATIVE DIAGNOSES:,1. Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2. New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1. Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2. New right hydronephrosis.,3. Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005. During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in. He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event. The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time. In that interval, he had a coronary artery bypass graft and was taken off of Plavix. Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated. I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer. We could not identify the right ureteral orifice, and he had a right ureteral stent placed. Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy. He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier. Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS: ,On exploration, there were multiple abnormalities outside the bladder as follows: There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface. There were two much smaller lesions also with a small white scar, with very little palpable mass. The larger of the two was resected and found to be a carcinoid tumor. There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes. The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined. There was a frozen section of the distal right external iliac lymph node that was negative. The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface. The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures. The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that. The rest of the large bowel appeared normal. There were no masses in the liver, and the gallbladder was surgically absent. There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion. The radiologist placed a radial arterial line and an intravenous catheter. Intravenous antibiotics were given for prophylaxis. We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline. Exploration was carried out with the findings described. The bladder was adherent and did appear immobile. Moist wound towels and a Bookwalter retractor was placed for exposure. We began by assessing the small and large bowel with the findings in the small bowel as described. We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture. We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum. The ureters were carefully dissected out and down deep in the true pelvis. The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber. I kept the ureters intact until we were moving the bladder off as described above. At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes. The common iliac lymph nodes remained stuck to the ureter. Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally. I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels. Clips were used to control the lymphatics distally. These lymph nodes were sent for frozen section, which was negative. We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it. The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those. On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down. I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate. At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally. The endopelvic fascia was incised. I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia. I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically. I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch. I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra. I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field. The bivalved prostate appeared normal. We then carefully inspected the rectal wall and noted to be intact. The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch. I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. The colon was divided proximal to the middle colic using a GIA-80 stapler. I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler. We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60. The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler. The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures. The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75. Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis. The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture. The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture. The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis. The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. We then matured our stoma through the umbilicus. We removed the plug of skin through the umbilicus and delivered the ileal segment through this. A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures. The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant. Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia. Interrupted stitches were placed as well. The subcutaneous tissue was irrigated and skin closed with surgical clips. The estimated blood loss was 2500 mL. The patient received 5 units of packed red blood cells and 4 units of FFP. The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.


Right lower pole renal stone and possibly infected stent. Cysto stent removal.

PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose. The patient was on vancomycin for the last 5 days.,BRIEF HISTORY: ,The patient is a 53-year-old female who presented with Enterococcus urosepsis. CT scan showed a lower pole stone with a stent in place. The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology. The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone. There was some pus that came out. The patient was cultured; actually it was negative at that time. The patient subsequently was found to have lower extremity DVT and then was started on Coumadin. The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE. The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact. The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers. The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated. Due to drug interaction, the patient was admitted for IV antibiotic treatment. The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed. Since the stone is not obstructing, there is no reason to replace the stent at this time. We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated. So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient. Risks, benefits, and options were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. The patient understood all the risks and benefits of removing the stent and wanted to proceed. The patient was brought to the OR. The patient was placed in dorsal lithotomy position. The patient was given some IV pain meds. The patient had received vancomycin and Levaquin preop. Cystoscopy was performed using graspers. The stent was removed without difficulty. Plan was for repeat cultures and continuation of the IV antibiotics.

cysto
cysto stent
cysto stent removal
infected
infected stent
lower pole
renal stone
stent
stone
surgery


PREOPERATIVE DIAGNOSIS:, Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:, General via endotracheal tube.,BLOOD LOSS:, Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and laid supine. General anesthesia was accomplished. A 16-French Foley was placed using aseptic technique. The patient was then placed on the operating table prone. His right flank was prepped and draped in a sterile fashion. At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed. The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire. The wire would not go down the ureter. Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained. After multiple attempts, access was lost. At this point, the tubes were left out of the kidney and sterile dressings were applied. The patient was then placed on another operating table supine. His genitalia were prepped and draped after removing his Foley catheter. Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous. The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope. The wire was removed. Contrast injection with good placement in the collecting system. The wire was replaced. The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance. The wire was removed leaving the double-J stent in good position. _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated. The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.

amplatz
catheter
cobra catheters
cysto
double j stent
french
nephrolithotomy
percutaneous
pollack catheter
residual stone
stent
surgery


Holmium laser cystolithalopaxy. A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate.

PREOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,OPERATION:, Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,ANESTHESIA: ,General.,INDICATIONS:, This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate. He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA: ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria. He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1. Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia. Prepped and draped in the dorsal lithotomy position. A 27-French Olympus rectoscope was passed via the urethra into the bladder. The bladder, prostate, and urethra were inspected. He had an obstructing prostate. He had marked catheter reaction in his bladder. He had a lot of villous changes, impossible to tell from frank tumor. He had a huge bladder calculus. It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone. There was still stone left at the end of the procedure. Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB. We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP. We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.

bladder
bladder calculus
calculus
catheterization
cystolithalopaxy
diabetic
holmium laser
holmium laser cystolithalopaxy
prostate
prostatism
stone
surgery
urethra
urinary
urinary tract infections


Cystoscopy and Bladder biopsy with fulguration. History of bladder tumor with abnormal cytology and areas of erythema.

PREOPERATIVE DIAGNOSIS:, History of bladder tumor with abnormal cytology and areas of erythema.,POSTOPERATIVE DIAGNOSIS: , History of bladder tumor with abnormal cytology and areas of erythema.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bladder biopsy with fulguration.,ANESTHESIA: , IV sedation with local.,SPECIMEN: , Urine cytology and right lateral wall biopsies.,PROCEDURE:, After the consent was obtained, the patient was brought to the operating room and given IV sedation. He was then placed in dorsal lithotomy position and prepped and draped in standard fashion. A #21 French cystoscope was then used to visualized the entire urethra and bladder. There was noted to be a narrowing of the proximal urethra, however, the scope was able to pass through. The patient was noted to have a previously resected prostate. On visualization of the bladder, the patient did have areas of erythema on the right as well as the left lateral walls, more significant on the right side. The patient did have increased vascularity throughout the bladder. The ________ two biopsies of the right lateral wall and those were sent for pathology. The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema. Bovie was also utilized to cauterize the areas of erythema on the left lateral wall. No further bleeding was identified. The bladder was drained and the cystoscope was removed. The patient tolerated the procedure well and was transferred to the recovery room.,He will have his defibrillator restarted and will followup with Dr. X in approximately two weeks for the result. He will be discharged home with antibiotics as well as pain medications. He is to restart his Coumadin not before Sunday.

abnormal cytology
bladder
bladder biopsy
bladder biopsy with fulguration
bladder tumor
cystoscopy
cytology
erythema
iv sedation
surgery
tumor


PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:, Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,SPECIMENS:, Urine sent for culture.,ABNORMAL FINDINGS: ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices. Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS: ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction. He has had a STING procedure performed but continues to have reflux bilaterally. Plan is for another injection.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, IV antibiotics were given. He was then placed in a lithotomy position with adequate padding of his arms and legs. His urethra was calibrated to 12-French with a bougie a boule. A 9.5-French cystoscope was used and the offset system was then used. His urethra was normal without valves or strictures. His bladder was fairly normal with minimal trabeculations but no cystitis noted. Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone. This was similarly found on the left side where the Deflux was not close to the orifice as well. It was slightly more difficult because of the amount impacted upon our angle for injection. We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect. Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding. Similar procedure was done on the left. This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed. There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection. At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra. The patient tolerated the procedure well and was in stable condition upon transfer to Recovery. A low-dose of IV Toradol was given at the end of the procedure as well.

bilateral vesicoureteral reflux
cystoscopy
cystoscopy under anesthesia
deflux
hit technique
hit/sting
hit/sting with deflux
sting procedure
surgery
ureteral
ureteral orifices
urethra
vesicoureteral
vesicoureteral reflux


PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones. The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A 0.035 glidewire was placed in the left system. Using graspers, left-sided stent was removed. A semirigid ureteroscopy was done. A stone was visualized in the mid to upper ureter. Using laser, the stone was broken into 5 to 6 small pieces. Using basket extraction, all the pieces were removed. Ureteroscopy all the way up to the UPJ was done, which was negative. There were no further stones. Using pyelograms, the rest of the system appeared normal. The entire ureter on the left side was open and patent. There were no further stones. Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. Over the 0.035 glidewire, a 26 double-J stent was placed. There was a nice curl in the kidney and one in the bladder. The patient tolerated the procedure well. Please note that the string was kept in place and the patient was to remove the stent the next day. The patient's family was instructed how to do so. The patient had antibiotics and pain medications at home. The patient was brought to recovery room in a stable condition.

basket extraction
cystopyelogram
distal ureteral stone
double-j stent
laser
laser lithotripsy
lithotripsy
shockwave lithotripsy
stent
stone
stones
string
surgery
ureteral stone
ureteroscopy


EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.

abdomen
biopsy
cholecystectomy
contrast
contrast administration
ct
ct guided
ct guided needle placement
ct of abdomen
ct-guided
ct-guided biopsy
decubitus position
hounsfield units
images
lower pole
mri
needle
needle placement
postcontrast
renal
renal lesions
renal mass
renal tumor
surgery
with and without


PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS: ,Gross hematuria.,OPERATIONS: ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS: ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed. There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs. The patient had hematuria. Cystoscopy revealed atypical biopsy. The patient came in again with gross hematuria. The first biopsy was done about a month ago. The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria. The options of watchful waiting, removal of the clots and biopsies were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed. Morbidity and mortality of the procedure were discussed. Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. The patient had been off of the Coumadin for about 4 days and INR had been reversed. The patient has significant amount of clot upon entering the bladder. There was a tight bladder neck contracture. The prostate was not enlarged. Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed. It took about half an hour to just remove the clots. After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected. This was lateral to the left ureteral opening. The base was coagulated for hemostasis. Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized. The back wall and the rest of the bladder appeared normal. Using 8-French cone-tip catheter, left-sided pyelogram was normal. The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation. The patient did have CT with contrast, which showed that the kidneys were normal. At this time, a #24 three-way irrigation was started. The patient was brought to Recovery room in stable condition.

bladder
bladder neck
bladder tumor
clot evacuation
clots
cystopyelogram
gross hematuria
hematuria
surgery
transurethral resection


Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.

PREOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic inflammatory disease.,2. Pelvic adhesions.,3. Pelvic pain.,4. Fibroid uterus.,5. Enterocele.,PROCEDURE PERFORMED:,1. Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2. McCall's culdoplasty.,3. Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS: ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia. On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated. The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY: ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities. On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis. There was also evidence of fibroid change in the right fundal aspect of the uterus. There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes. There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate. She was then prepared and draped in the normal sterile fashion. A Foley catheter was initially placed and was noted to be draining clear to yellow urine. A weighted speculum was placed in the patient's vagina. The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus sounded to 7 cm and the cervix was then progressively dilated. A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator. At this time, after the gloves were changed, attention was then turned to the patient's abdomen. A small approximately 1 cm infraumbilical incision was made with the scalpel. A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures. A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope. On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions. There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance. At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope. A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope. Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site. The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper. The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time. Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper. An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament. At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic. In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted. At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers. The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated. The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure. At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic. The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure. The weighted speculum was placed into the patient's vagina. At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb. The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure. The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps. The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position. The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly. Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly. At this time, two curved Heaney clamps were placed across the uterine artery on the right. This was then transected and suture ligated with #0 Vicryl suture. The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture. Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture. This second clamp was then advanced to capture the vasculature and the cardinal ligament complex. This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff. Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology. At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure. Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position. Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly. The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum. Two additional sutures medially were placed and these were tagged and not tied in place. A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized. This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches. At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg. The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic. The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time. The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time. The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen. The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia. The Steri-Strips were placed. The patient tolerated the procedure well and taken to recovery in stable condition. Sponge, lap, and needle counts were correct x2. The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes. The patient will have her Foley catheter maintained for approximately 7 to 10 days.

laparoscopic assisted vaginal hysterectomy


TITLE OF OPERATION:, Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache. All endocrine labs were normal. Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:, Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended. The patient was then prepped and draped in the usual sterile fashion. With the assistance of fluoro and mapping the localization, the right nostril was infiltrated. Dr. X will dictate the procedure of the approach. Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling. Once the operating microscope was in the field, at this point, the drilling was completed. The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor. This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down. Once this was completed, there was no evidence of any bleeding. The endoscope was then used to remove any residual fragments __________ with the arachnoid. Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X. She was reversed, extubated, and transported to the ICU in stable condition. Blood loss, minimal. All sponge, needle counts were correct.

cystic
cystic suprasellar tumor
endoscopic
microsurgical
microsurgical transnasal resection
suprasellar
surgery
transnasal
transnasal resection
tumor


CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.

REASON FOR EXAM: This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE: The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient. The patient understood. All questions were answered, and informed consent was obtained. With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney. Conscious sedation was utilized with the patient being monitored. The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach. Two biopsy specimens were obtained and placed in 10% formalin solution. CT documented needle placement. Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly. I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding. The bleeding stopped. The co-axial sheath was then removed. Bandage was applied. Hemostasis was obtained. The patient was placed in the supine position. Postbiopsy CT images were then obtained. The patient's hematoma appeared stable. The patient was without complaints of pain or discomfort. The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable. The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS: Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney. Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass. Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass. There are small droplets of air within the hematoma. No hydronephrosis is identified.,CONCLUSION:,1. Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2. Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.

biopsy
ct
ct guided
ct guided biopsy
ct guided needle placement
ct localization
embolization
gelfoam pledgets
hematoma
inferior pole
kidney
mass
needle placement
renal mass
surgery


PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood.

calvarium
cookie cutter type
craniotomy
dura
frontotemporal
frontotemporal craniotomy
galea
hematoma
subacute subdural hematoma
subdural
subdural hematoma
surgery
syncopal
temporalis
temporalis muscle
weitlaner


Left temporal craniotomy and removal of brain tumor.

PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.

brain
brain tumor
burr hole
cortex
corticectomy
craniotome
craniotomy
frozen section
glioblastoma multiforme
lorenz titanium plate
surgery
temporal
temporal craniotomy
temporal lobe
temporoparietal
tumor
ventricle
white matter


Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric.

PREOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,PROCEDURE:, Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia. He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency. He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury. His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy. The images were brought up on the electronic imaging and confirmed that this was a left-sided condition. He was fixed in a three-point headrest. His scalp was shaved and prepared with Betadine, iodine and alcohol. We made a small curved incision over the temporal, parietal, frontal region. The scalp was reflected. A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created. After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain. The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up. We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline. After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline. We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates. The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment. Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this. I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.

bur hole
craniotomy
hematoma
subdural
subdural hematoma
subdural space
surgery
temporal craniotomy