DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left hydronephrosis.
2. Urosepsis.
POSTOPERATIVE DIAGNOSES:
1. Bilateral severe hydronephroureterosis, left greater than the right.
2. Bilateral ureteral strictures.
3. Sepsis secondary to above.
4. Rule out right renal failure with decreased function.
5. Open prostatic fossa with no obstruction.
OPERATION PERFORMED:
1. Bilateral retrograde pyelograms.
2. Right ureteroscopy with ureteral dilatation of stricture.
3. Bilateral ureteral stents and placement of Foley catheter.
SURGEON: John Doe, MD
ANESTHESIA: General monitored anesthesia care.
INDICATIONS FOR OPERATION: This is a (XX)-year-old male who was admitted to the medical service. This is his second admission secondary to urosepsis. The patient subsequently on readmission had a fever of 103.4 and has been on IV antibiotics. Renal ultrasound revealed a mild right hydronephrosis present, and the right kidney was vaguely seen on the study. The patient had a history, according to the daughter, of having some urethral or ureteral strictures in the past and has been seeing an urologist in the past, where he has had a TURP performed. The patient’s culture is showing mixed organisms, and therefore, because of this, we were asked to evaluate the patient and to determine the reason for the patient having this persistent UTI and readmission to the hospital because of same. The history was obtained from the daughter.
DESCRIPTION OF OPERATION: After the patient was brought to the OR suite, again the procedure was explained to the patient’s family. The patient then was carried to the cystoscopy suite, placed on the surgical table, given IV sedation and general MAC. After appropriate level was achieved, he was placed in the dorsal lithotomy position, prepped with Betadine, draped in aseptic fashion, and 2% Xylocaine was infused into the urethra.
The scope entered without difficulty. Prostatic fossa was open without any signs of strictures. The orifices were very difficult to visualize secondary to severely trabeculated bladder with the deviation of the trigone. The patient was given methylene blue. We then found and localized the right orifice, which was cannulated. It was difficult to cannulate because of the blockage, and we did pass a guidewire. Once in the orifice, we took the ureteroscope and passed it along the guidewire, and we were able to see from retrograde injection, a very tortuous dilated collecting system. Once in the collecting system, with the scope, we were able to dilate the stricture and to leave the guidewire as a lead. Once this was completed, we then backloaded a 24 cm, 6 French double-J into the collecting system to drain the right side.
Then, attention was given to the left. The left orifice was even more difficult to ascertain because of its deviation to the left lateral wall. It was in an area, which appeared to be contained to the ridge of the trigone, causing deviation. However, once we catheterized this area by placing the scope with a very oblique angle, we were able to pass the cone tip to open up the blockage. Once the blockage was open, we passed a guidewire. Then, we injected dye by backloading the guidewire and injecting it through the colon; it now passes throughout the ureter. The collecting systems showed marked hydronephrosis with pyelocaliectasis, dilated ureter down to the point of the bladder.
Once this was obtained, we decided because of the ureter now being open with blue dye coming from around the area that was blocked and opened with a cone tip, we would just leave a double-J stent. A 24 cm double-J was then placed over the guidewire and placed successfully in the collecting system. Now that both sides are now cannulated, we will observe the patient for good drainage of his kidneys.
