DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Renal failure, bilateral hydronephrosis.
POSTOPERATIVE DIAGNOSIS: Renal failure, bilateral hydronephrosis.
OPERATION PERFORMED: Cystoscopy with bilateral retrograde pyelograms and bilateral stent placement.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
SPECIMENS OBTAINED: Bilateral renal pelvis cultures.
TUBES PLACED: On the left, a left ureteral stent, 6 French x 28 cm. On the right is 6 French x 26 cm as well as an 18-French Foley catheter.
ESTIMATED BLOOD LOSS: 5 mL.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable to the PACU.
OPERATIVE FINDINGS: The patient did have grossly strictured ureters bilaterally with the left being much worse than the right, making placement of the stent on the left quite difficult. The patient also did have some purulent-looking urine proximal to the strictures, which was obtained and sent for culture. The patient did have grossly hydronephrotic collecting systems proximal to these strictures as well as evidenced on the retrograde pyelograms.
DESCRIPTION OF OPERATION: The patient was brought back to the cystoscopy suite by the OR and anesthesia staff and placed on the cystoscopy table. The patient was smoothly induced with anesthesia and intubated without difficulty. The patient was then brought to the bottom of the cystoscopy table, placed in the dorsal lithotomy position, and his genitalia prepped and draped in sterile fashion.
At this point, a rigid cystoscope was passed through the urethra into the bladder without difficulty. On systematic examination of the bladder, there were no gross abnormalities of the mucosa or any ulcerations or tumors visualized. The ureteral orifices were in normal anatomic configuration bilaterally. At this point, a wire was attempted to be passed into the left ureteral orifice and up into the left collecting system. A Glidewire was introduced into the left UO, and with some amount of difficulty, was passed up into the left renal pelvis. At this point, a Pollack catheter was placed over the wire and able to be placed approximately halfway into the distal ureter. A bit of contrast was injected showing a medial defect of the left ureter, showing some evidence of a ureteral fistula. The wire was passed past this point, and the Pollack passed over the wire past this fistulous tract. Once the wire and Pollack catheter were advanced past the mid ureter, where the stricture was, the worst gross purulent-looking urine was obtained and sent for culture. A retrograde pyelogram was then obtained of the left collecting system, which showed hydronephrosis and caliectasis.
At this point, the Pollack catheter was removed, and a 6-French x 28 cm stent was attempted to be placed over the wire into the left collecting system. We encountered much difficulty in passing the stent through the strictured area with marked accordion-like collapse of the ureteral stent on itself. The stent was still able to be pushed through the strictured area up into the left renal pelvis, and upon withdrawal of the wire, a curl was seen in the left renal pelvis under fluoroscopic guidance, and a curl was seen in the bladder as well. The stent did decompress, and the accordion-like collapse of the stent did resolve, and the stent ended up looking more normal in appearance.
Attention was then turned to the right ureteral orifice where the 0.035 Glidewire was passed with minimal to moderate difficulty into the right collecting system. A Pollack was passed over this, and retrograde pyelogram of the right collecting system was obtained showing mild to moderate hydronephrosis as well. The Pollack was removed, wire was replaced, and 6-French x 26 cm stent was placed with moderate difficulty in the right collecting system. Good curls were visualized both in the renal pelvis and the bladder by fluoroscopic guidance and on direct visualization respectively.
At this point, the bladder was emptied, and the cystoscope was removed, and the patient was transitioned to the PACU for postoperative resuscitation. This procedure was fairly difficult due to the fact that the patient had fairly impressive ureteral strictures bilaterally with the left being markedly worse than the right.
