DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left kidney stones.
POSTOPERATIVE DIAGNOSES: Left kidney stones.
OPERATION PERFORMED:
1. Second left percutaneous nephrolithotripsy.
2. Cystoscopy with right ureteral stent removal.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General anesthetic.
SPECIMENS: None.
DRAINS: A 16-French Councill tip nephrostomy tube.
ESTIMATED BLOOD LOSS: None.
INDICATIONS FOR OPERATION: The patient is a female who we have been following with a known left staghorn kidney stone. She has undergone a previous left percutaneous nephrolithotripsy. As well, she had had a previous retained right ureteral stent, which we had done a stent exchange previously on, and the stent is still in place. The patient comes in now for removal of the remaining stone burden and removal of her right ureteral stent.
DESCRIPTION OF OPERATION: The patient was brought to the procedure room and placed on the table in the supine position. She was given general anesthetic and intubated. She was then placed in frog-leg position, draped and prepped in a sterile fashion.
We passed a flexible cystoscope through the urethral meatus. Urethroscopy was normal. The scope was advanced into the bladder. The stent could be seen existing in the right ureteral orifice. The distal end of this was grasped and it was pulled free off the patient without resistance. The patient was then placed in the prone position. All pressure points were padded. The patient had a previously placed nephrostomy tube in with ureteral access.
A 0.035 sensor guidewire was passed down this until it could be seen coiling in the renal bladder. The nephrostomy tube was removed over the wire. A double introducer sheath was placed over the existing wire and a second super-stiff wire was passed to the level of the bladder as well. Over the sensor wire, a NephroMax balloon was passed. This was inflated with 12 cm of water. The head did advance to what we felt was level to the collecting system. Over this, the access sheath was passed and then the balloon was removed. The nephrostomy tube was passed into the collecting system. There was no bleeding noted.
We then performed a nephrostogram. There was still some residual stone in the upper pole. We passed a flexible cystoscope through this point after removing the rigid nephroscope. There were just small fragmentations, which we were able to flush downwards into the renal pelvis. The bulk of the stone burden, approximately 2 cm, was in a lower pole calyceal system, which we had been unable to locate the previous time. It was very difficult to locate this, but using a sensor guidewire, I was able to pass a guidewire through what appeared to be a stenosed infundibulum and into the calyceal system. It was a very sharp, severe angle, but we were able to eventually pass the scope through the stenosed infundibulum into the calyceal system. We were then able to flush a good portion of the fragments, which had undergone previous extracorporeal shock-wave lithotripsy, out of this system. We were able to basket some of the larger pieces.
At the end, there were some fragments throughout this lower calyceal system that we were unable to successfully remove. After multiple passes with baskets and flushing, we were unable to remove these and felt at this time to stop the case. Over the sensor guidewire, we passed a 16-French Councill tip catheter to the level of renal pelvis, 2 mL inflated in the balloon. The access sheath was removed. There was no bleeding noted. We had light pink urine at the end of the case. The second super-stiff wire was removed as well and the Councill tip catheter was sutured to the skin with 2-0 silk. The patient was then transferred to the postoperative care unit in stable condition.
