Operative Note

Operative Note

PATIENT: Robert Vance

DATE OF BIRTH: 14/05/1958

MEDICAL RECORD NUMBER: 84920174

DATE OF SURGERY: 10/24/2023

Preoperative Diagnosis

• Left obstructing proximal ureteral calculus with hydronephrosis

Postoperative Diagnosis

• Left obstructing proximal ureteral calculus with hydronephrosis

Procedure

• Cystourethroscopy
• Left ureteroscopy with holmium laser lithotripsy and stone basket extraction
• Left double-J ureteral stent placement

Surgeon

• David Canes, M.D.

Assistant

• Sarah Jenkins, PA-C

Anesthesia

• General endotracheal anesthesia

IV Fluids

• 800 mL Lactated Ringer's

Estimated Blood Loss

• < 5 mL

Drains

• 1. 6 Fr x 26 cm left double-J ureteral stent

Complications

• none

Specimens

• 1. Left ureteral stone fragments for compositional analysis

Indications

The patient is a 65-year-old male presenting with intractable left flank pain and nausea. CT abdomen/pelvis demonstrated an 8 mm obstructing left proximal ureteral calculus with moderate hydroureteronephrosis. Medical expulsive therapy failed.

The risks, benefits, advantages, disadvantages, side effects, and alternatives of the procedure were reviewed, and he wished to proceed. Common risks including bleeding, infection, ureteral perforation, stricture formation, steinstrasse, stent discomfort, and need for additional procedures were reviewed, and all questions were answered.

Procedure in Detail

After informed consent was obtained and timeout performed, the patient was induced under general anesthesia and placed in the dorsal lithotomy position. Preoperative cefazolin 2 g IV once was administered. The genitalia were prepped and draped in standard sterile fashion. A 22 Fr rigid cystoscope was introduced per urethra. The urethra was normal. The prostate showed mild trilobar hypertrophy. The bladder mucosa was normal without masses or stones. Both ureteral orifices were in normal anatomic position. A 0.035-inch sensor wire was advanced through the left ureteral orifice into the renal pelvis under fluoroscopic guidance. A safety wire was placed via dual-lumen catheter. A flexible ureteroscope was advanced over the working wire to the proximal ureter, where an 8 mm impacted yellow-brown calculus was visualized. Using a 200-micron holmium laser fiber at 0.8 J and 10 Hz, the stone was fragmented into dust and small extractable pieces. Larger fragments were retrieved using a 1.9 Fr zero-tip nitinol basket and sent for analysis. Pyeloscopy of all calyces confirmed no residual significant stone burden. The ureteroscope was withdrawn under direct vision, confirming intact ureteral mucosa without perforation. A 6 Fr x 26 cm double-J ureteral stent was advanced over the wire under fluoroscopy with good proximal and distal curls. The bladder was emptied and the cystoscope removed. The patient tolerated the procedure well and was transferred to the PACU in stable condition.

Plan

• Discharge home today once voiding trial passed.
• Prescribe tamsulosin (Flomax®) 0.4 mg PO daily, phenazopyridine (Pyridium®) 200 mg PO TID PRN for 3 days, and paracetamol (acetaminophen, Tylenol®) 650 mg PO Q6H PRN.
• Office follow-up in 1 week for cystoscopic stent removal.

David Canes, M.D.

10/24/2023