DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bladder neoplasms.
POSTOPERATIVE DIAGNOSIS: Bladder neoplasms.
OPERATION PERFORMED: Transurethral resection of the bladder (large).
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This patient is a (XX)-year-old woman with severe pelvic and bladder pain, refractory to antibiotic therapy. Her urinalysis and urine cultures were negative. Cystoscopy demonstrated marked inflammatory changes of the right and left lateral bladder wall, localized. Bladder biopsy was consistent with acute and chronic inflammation. In light of the suspicious appearance for carcinoma in situ, we recommended proceeding with further diagnostic resection to rule out carcinoma in situ. The risks of bleeding, infection, and bladder perforation were described to the patient.
OPERATIVE FINDINGS: Marked acute and chronic inflammatory changes of both lateral walls, approaching the midline, away from the trigone. There were no papillary lesions.
DESCRIPTION OF OPERATION: After obtaining adequate general anesthesia, the patient was placed in the dorsal lithotomy position. The genitals were prepped with Betadine and draped with sterile drapes. Cystoscopy with 21-French cystoscope demonstrated the findings above. The cystoscope was removed and was replaced with a 25-French continuous flow resectoscope sheath using a Timberlake obturator. The obturator was exchanged for a bipolar resectoscope device.
Starting on the patient’s left side, an area of approximately 5 cm was resected into the muscle, taking care not to perforate the bladder. The entire resection site was fulgurated as well as all the abnormal mucosa.
Attention was then turned to the right lateral and posterior bladder walls where a similar lesion was identified. Similar resection was carried out in this area, once again taking care not to perforate. The resection site and the surrounding mucosa were fulgurated for hemostasis.
The resectoscope was removed and was replaced with a 20-French Foley catheter. Urine was clear. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
