DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Urinary retention x2.
2. Rule out neurogenic bladder secondary to diabetes and alcohol.
3. Rule out bladder outlet obstruction.
POSTOPERATIVE DIAGNOSES:
1. Spastic neurogenic bladder.
2. Bladder neck obstruction from carcinoma of the prostate.
PROCEDURES PERFORMED:
1. Cystometric study.
2. Cystoscopy.
3. SLV GreenLight laser vaporization of the prostate.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION: After informed consent was signed, the patient was brought to the cystoscopy room. No premedication was given. He had an indwelling Foley catheter for urinary retention, which was draining brownish urine. The patient was kept in lithotomy position. Genitalia were prepped with Betadine and draped in the usual fashion after the Foley catheter was removed. Bard cystometric apparatus was used. A red rubber catheter was inserted. About 5 mL of urine was obtained for culture and sensitivity. The fiberoptic probe was inserted into the red rubber catheter and cystometric study was performed. The first desire to void was felt at 75 mL with the bladder pressure of 25 cm, urge to void was felt at 95 mL with the bladder pressure of 59 cm. Bladder capacity was 145 mL with the bladder pressure of 85 cm. At this time, the patient was asked to empty his bladder. The maximal detrusor pressure was 95 cm. These parameters are indicative of spastic neurogenic bladder.
At this time, the patient was given general anesthesia. The catheter was removed and a 21 French ACMI cystoscope was inserted. There was resistance in the prostatic fossa. The bladder was examined with 70 degree lens followed by Foroblique lens. There were two old clots in the bladder, which were removed. The bladder shows 2 to 3+ trabeculation. No diverticula. No tumors noted. There was uniform congestion of the bladder. There were no tumors seen. The bladder capacity was fairly large apparently from retention. The prostatic urethra showed mild to moderate obstruction. The supramontanal urethra measured about 4 to 4.5 cm. The lateral lobes were prominent but not coming to the midline. The cystoscopic findings could not explain why the patient got urinary retention x2.
Hence, it was decided to proceed with the laser vaporization this time. SLV GreenLight laser was brought in. The entire operating team followed the laser precautions including protective glasses for the patient and all the operating team. The 23 French continuous flow cystoscope was inserted and the landmarks were visualized. The laser was used to vaporize the prostatic tissue starting at 6 o’clock. The right lateral lobe was vaporized initially from bladder neck to the middle from 6 o’clock to 10 o’clock. Then, the left lateral lobe was vaporized from 6 o’clock to 2 o’clock and again stopping short of verumontanum, stopping cephalad to verumontanum. Care was taken not to vaporize the posterior portion of the prostate too deeply because of the radioactive seed implants, for fear of rectoprostatic fistula. Then, the scope was turned 90 degrees on each side and the anterior portion of the prostate was vaporized. Satisfactory vaporization was carried out. The prostatic urethra was wide open.
After this procedure, there was no bleeding. The total energy used was 18,120 joules. At the end of the procedure, the bladder and the prostatic urethra were reexamined with 70 degree lens followed by Foroblique lens. The integrity of the bladder was maintained. At this time, the cystoscope was removed. An 18 French Foley catheter was inserted. Irrigation returns were clear. The patient was transferred to the recovery view. In view of the patient’s comorbidities, it was decided to admit the patient for 23 hour observation. The patient’s vital signs were stable in the recovery room.
