PREOPERATIVE DIAGNOSIS: Left renal calculus.
POSTOPERATIVE DIAGNOSIS: Left renal calculus.
PROCEDURES PERFORMED:
1. Cystoscopy.
2. Left ureteral dilation.
3. Left ureteroscopy.
4. Stone manipulation.
5. Left ureteral stent placement.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
FINDINGS: The left ureteral orifice was small requiring dilation, which was performed without difficulty. The ureteroscopy revealed an approximately 4 mm stone in the lower pole, which was grasped with a basket and pulled out. There were also multiple calcifications seen within the wall of the papilla but no other free floating stones. The patient also has a known 4 cm left renal mass and is possibly a candidate for left partial nephrectomy.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman who presented with left renal colic. A CT scan showed multiple stones in the left kidney, the largest being approximately 4 mm. He was consented for cystoscopy with left ureteroscopy and stone manipulation. He was also found to have an exophytic mass on the left kidney, which was read as a Bosniak III, which may potentially need partial nephrectomy in the future.
DESCRIPTION OF PROCEDURE: The patient was given preoperative antibiotics and proper consent was obtained. He was taken to the cystoscopy suite and moved onto the table in the supine position.
After a smooth induction of general anesthesia, his position was changed to the lithotomy position. His genitalia prepped and draped in a typical fashion. The 22 French rigid cystoscope was passed through the urethra into the bladder.
Once in the bladder, the left ureteral orifice was identified. It appeared quite small. We were able to pass a Glidewire through the scope up the left ureteral orifice to the left kidney. The balloon dilator was then passed over the indwelling wire into the ureteral orifice and dilated in the typical fashion.
Then, the balloon dilator was removed. The scope was then removed, and the Glidewire was left in place in the kidney. The flexible ureteroscope was then passed over the indwelling wire up to the level of the kidney.
We then looked around in the kidney and saw multiple calcifications in the walls of the kidney but no free floating stone. In the lower pole, there was an approximately 4 mm stone that was seen.
At this point, we passed the basket through the scope and attempted to grasp the stone. The stone was dropped in transfer unfortunately while we were pulling the ureteroscope out.
At this point, we elected to pass a safety wire up. The cystoscope was therefore placed back into the bladder through the urethra. The Glidewire was passed up the left ureteral orifice up to the level of the kidney. The cystoscope was removed.
A dual lumen access sheath was passed over the indwelling wire. A second wire was passed through the dual lumen sheath. The flexible ureteroscope was then passed over one of the wires up to the level of the kidney. That wire was removed and the other wire was left in place for a safety wire.
Again, we searched throughout all of the poles of the kidney. The upper pole revealed no free floating stones. There were no stones in the mid pole. In the lower pole calix, an approximately 4 mm stone was identified. The zero-tip nitinol basket was passed through the ureteroscope and used to grasp the stone. The stone was grasped and pulled out through the ureter. This was passed off the field for pathology.
The cystoscope was then passed back into the bladder through the urethra. The indwelling Glidewire was back loaded through the cystoscope using the pusher for the ureteral stent. A 6 French variable length stent was then passed over the indwelling wire up to the level of the kidney. The wire was pulled. A curl was confirmed in the kidney and a curl was confirmed within the bladder.
The patient was awakened from anesthesia and transferred to the postanesthesia care unit in stable condition. He will be discharged home with antibiotics and pain medications. He will follow up in the clinic in two to three weeks, at which time we will need to arrange his stent removal as well as possible left partial nephrectomy.
