OR: Ureteroscopy and laser lithotripsy

DATE OF SURGERY: 11/01/2024 PATIENT: John Doe DOB: 05/15/1980 MEDICAL RECORD NUMBER: 123456789 SURGEON: David Canes, M.D. ASSISTANTS: None PREOPERATIVE DIAGNOSIS: Urolithiasis, 8 mm stone in the left distal ureter POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: 1. Cystoscopy 2. Ureteroscopy and laser lithotripsy, left side. Stone size: 8 mm, Location: distal ureter 3. Retrograde pyelogram KEY DETAILS: Flexible ureteroscopy Ureteral access sheath used ANESTHESIA: General. INTRAVENOUS FLUIDS: 1000 mL of crystalloid. ESTIMATED BLOOD LOSS: 0 mL DRAINS: 6F x 26 cm double pigtail ureteral stent LASER SETTINGS: Laser type: Holmium Settings: Power 20 W, Frequency 10 Hz, Pulse energy 1.0 J. Dusting technique used COMPLICATIONS: None. INDICATIONS: John Doe, a 44-year-old male, with a diagnosis of urolithiasis. The patient had extensive counseling about treatment options and, after ample opportunity to ask questions, elected to undergo ureteroscopy and laser lithotripsy. The risks of the procedure were extensively discussed with the patient. Intraoperative risks included but were not limited to the following: bleeding, ureteral injury, perforation, infection, and need for additional procedures. Postoperative risks included but were not limited to urinary tract infection, stent discomfort, hematuria, and potential need for further interventions, ureteral stricture, etc. Cardiovascular risks included deep vein thrombosis, pulmonary embolus, myocardial infarction, stroke, and death were included in informed consent. The patient took opportunities to ask questions which I answered to the best of my ability. The patient wished to proceed. OPERATIVE PROCEDURE IN DETAIL: After proper informed consent was obtained, the patient was brought to the operating suite. Preoperative prophylactic antibiotics were administered. Satisfactory general anesthesia was established. The patient was positioned in the lithotomy position with great care to pad all bony prominences. After a sterile prep and drape, a procedural time-out was called using a standardized checklist. Cystoscopy was performed, and the bladder was inspected and found to be normal. The left ureteral orifice was identified, and a guidewire was advanced up the ureter under fluoroscopic guidance. The wire was secured to the drape as a safety wire. A second working wire was placed. All wires were 0.038 zip wires. A ureteral access sheath was placed fluroscopically prior to advancing the flexible ureteroscope, which was then passed to the level of the stone. The stone was visualized and evaluated. The Holmium laser was used to fragment the stone. Settings included a power of 20 W, frequency of 10 Hz, and pulse energy of 1.0 J. A dusting technique was utilized to break the stone into fine fragments. Upon completion, the ureteroscope was withdrawn. The ureter was inspected for any residual stones or injury. A 6F x 26 cm stent was placed for ureteral drainage, deployed in standard fashion with a good curl demonstrated proximally in the renal pelvis and distally under direct vision. COMPLICATIONS: None. The patient was awakened from anesthesia and transferred to the recovery room in stable and satisfactory condition. There were no immediate complications. I was present throughout. PLAN: The patient will be monitored for any signs of infection or complications. Follow-up in the clinic in two weeks for stent removal. David Canes, MD 11/01/2024 14:30