Urologist Procedure Note

Urologist Procedure: Cystoscopy with Ureteroscopy and Laser Lithotripsy for left ureteral calculus. General anaesthesia was administered via Laryngeal Mask Airway (LMA) by Dr. Alice Green. The procedure commenced at 10:30 and concluded at 11:15 on 1 November 2024. A 6-Fr ureteroscope was advanced to the left ureter, identifying a 7mm calculus located in the mid-ureter. A Holmium laser was used to fragment the stone. Indication: Left ureteral calculus causing severe hydronephrosis and intractable renal colic, unresponsive to conservative management. Finding: Successful fragmentation of a 7mm left mid-ureteral calculus. No perforation or significant bleeding observed. Ureteral mucosa appeared healthy post-lithotripsy. A 4.8-Fr double J stent was successfully inserted from the left renal pelvis to the bladder. Plan: Patient to be discharged today with oral analgesia (paracetamol and ibuprofen as needed) and alpha-blocker (tamsulosin 0.4mg daily for 2 weeks). Follow-up appointment scheduled in 2 weeks for stent removal in the clinic. Renal ultrasound to be performed in 3 months to assess for residual fragments and hydronephrosis resolution. Advised to increase fluid intake and strain urine.