DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left renal calculi.
2. Ureteral stent.
POSTOPERATIVE DIAGNOSES:
1. Left renal calculi.
2. No evidence of left renal calculus in the left ureter.
OPERATION PERFORMED: Removal of left ureteral stent.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION AND FINDINGS: The patient was brought to the cystoscopic suite, and the patient was put in the supine lithotomy position after satisfactory general anesthesia. The skin of external genitalia was then prepped with Betadine and draped in a sterile manner. A 21 size French cystourethroscope was inserted through the urethral meatus, and panendoscopy examination was performed.
On examination, the urethra showed it was essentially normal, and there was no evident stenosis or stricture. No other abnormal injury, and the scope was passed through the proximal urethra and into the bladder. Examination of the bladder neck showed no evidence of bladder neck contracture. Examination of the trigone area showed both ureteral orifices in normal location and the morphology was normal. The stent on the left side showed good curving on the distal end. Examination of the bladder showed the base, dome, and lateral bladder walls. The bladder showed no abnormal lesions. No evident stones.
Alligator forceps were then applied, and the stent was pulled down all the way through the urethral orifice, and a guidewire was then passed through the ureteral stent all the way into the left kidney, and this was performed under fluoroscopic guidance. The urethroscopic examination was then followed by going through the left distal ureteral junction and showed no evidence of narrowing. The area of the patient’s scar in the distal ureter was dilated and was wide open, and inspection all the way to the ureter showed no evidence of stones.
The scope was then removed, and the bladder was emptied, and the patient tolerated the procedure well. Upon completion of the procedure, the patient was sent back to the recovery room in good condition.
