DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Bladder mass.
POSTOPERATIVE DIAGNOSIS:
Bladder mass.
PROCEDURE PERFORMED:
Cystoscopy with transurethral resection of bladder tumor.
SURGEON: John Doe, MD
ANESTHESIA: General.
SPECIMENS: Bladder tumor chips.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old female who was found to have an incidental bladder mass on pelvic ultrasound. CT scan was subsequently performed, which confirmed the probability of a filling defect in the bladder. Cytology has come back negative. The patient presents for cystoscopy with transurethral resection of presumed bladder tumor. The patient has been made aware of the potential risks, benefits, complications, and alternatives to undergoing this procedure and agrees to proceed.
DESCRIPTION OF PROCEDURE: The patient was correctly identified and informed consent was obtained. She was brought to the operating room where, once sufficient anesthesia had been rendered, she was prepped and draped in the lithotomy position. Cystoscopy was initially performed using a rigid 17-French cystoscope. This demonstrated the presence of a papillary appearing bladder tumor just posterior to the left ureteral orifice. It did have a superficial appearance. It was estimated to be 2.5 to 3 cm in diameter. The remainder of the bladder was normal with normal mucosa and no evidence of other lesions.
At that point, the cystoscope was removed and the resectoscope continuous flow was placed into the bladder. A 24-French scope was used. A 24-French cutting loop was then used to carefully resect the bladder tumor off the floor of the bladder. Care was taken not to resect over the ureteral orifice. Care was also taken to get deep enough to include muscle in the resected fragments. Once the tumor was completely resected, the coagulation current was used to cauterize the base of the resection margin as well as the edges. Again, care was taken not to cauterize over the ureteral orifice.
Once it was felt that sufficient hemostasis had been achieved, the bladder tumor fragments were evacuated from the bladder using Ellik evacuator. Cystoscopy then confirmed that no remaining chips were present. The scope was removed and a 16-French Foley catheter was placed into the bladder. Anesthesia was reversed, and the patient was taken to the recovery room in satisfactory condition.
DISPOSITION: The patient will likely be discharged home when awake and alert. She will go home with the Foley catheter to allow the resected area to heal. We will remove the catheter in 48 hours in the office. The patient will follow up in 2 weeks’ time for a postoperative visit to discuss pathology. Scripts for Levaquin, Pyridium, and Vicodin were written. The patient tolerated the procedure well.
