DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left kidney stones.
POSTOPERATIVE DIAGNOSES:
1. Left kidney stones.
2. Suspected left ureteropelvic junction obstruction.
OPERATION PERFORMED:
Left percutaneous nephrolithotripsy and left antegrade ureteral stent placement.
SURGEON: John Doe, MD
ANESTHESIA: General.
SPECIMENS: Kidney stones.
DRAINS: A 16 French Foley catheter and a 22 French nephrostomy tube.
IMPLANTS: A 6 x 24 French double-J left ureteral stent.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with multiple left kidney stones. She had approximately 15-30 stones within the renal pelvis and lower collecting system. Based upon this, we felt left percutaneous nephrolithotripsy was indicated to manage this. At the time of her nephrostomy tube, the interventional radiologist had concern for left ureteropelvic junction obstruction due to the narrowness of the ureteropelvic junction.
DESCRIPTION OF OPERATION: The patient was brought to the procedure room and placed on the table in the supine position. She was given a general anesthetic and intubated. She was then turned into the prone position and all pressure points were padded. Using the previously placed nephrostomy tube, which has an internal and external stent, a 0.035 Sensor guidewire was passed down the stent until we could see it curl in the renal pelvis. The existing nephrostomy tube was removed. We then made an approximately 1 cm incision at the level of the wire. We then passed the double introducer sheath down the ureter. The inner sheath was removed and a second super-stiff wire was passed to the level of the bladder. The double introducer was removed. The super-stiff wire was placed as a safety wire and clamped to the drapes. Over the central wire, a NephroMax balloon was passed. This was passed to the level we felt was the lower calyceal system where the entrance of the nephrostomy tube was. This was then inflated to 14 cm of water, and over this, the introducer sheath was passed with no resistance.
At this point in time, the NephroMax balloon was removed. We then passed a rigid nephroscope to the level of the renal pelvis. Again, multiple stones measuring in size from 3-6 mm were noted. These were grasped with three-pronged grasper with multiple passes with the nephroscope until we were able to remove all the stones. We then viewed the entire system with the flexible cystoscope and the smaller stones were noted. We then basketed with Zero Tip basket. The rigid nephroscope was re-passed and basketed with the three-pronged grasper. With the flexible cystoscope, we were able to evaluate the uteropelvic junction. There did seem to be some narrowness there. It had been slightly dilated during the procedure but noted to be a concentric ring at that level.
Due to the likely narrowness of the ureteropelvic junction, we deflected the placement of stent. Therefore, over the wire and using antegrade, passed a 6 x 24 double-J stent. Once the wire was removed, this was noted to curl nicely in the renal pelvis above under direct vision and the bladder below under fluoroscopic imaging. The introducer sheath was then removed, and over the super-stiff wire, we passed a 22 French Council-tip catheter to the level of the renal pelvis. This was inflated with 3 mL of water. Nephrostogram was performed and showed no residual stones. There was no significant drainage of contrast down the ureter. At this time, the nephrostomy tube was sutured to the skin. Then, the patient was transferred to the postoperative care unit in stable condition.
