Manipulative Procedures Example 3

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Report of Cystoscopy

  • Name: Sammy Kidd
  • Service: Medicine
  • Hospital No.: 000021
  • Sex: Male
  • Age: 56
  • Race: White
  • Date: 01/14/91

  • Pre-operative Diagnosis: Carcinoma of the bladder
  • Surgeon: K. U. Bladd, MD
  • Assistant Surgeon: Urie Sac, MD
  • Operative Diagnosis: Carcinoma of the bladder
  • Operation: Cystoscopy; random biopsies of bladder; bilateral retrograde pyelography;
  • TUR-primary bladder carcinoma

Description of Operation:

The patient was placed in the lithotomy position. Under satisfactory general anesthesia, the cystoscope was inserted into the bladder and urine was sent for cytology. At this point, a careful evaluation of the bladder revealed a relatively extensive localized exophytic lesion in the right superior lateral portion of the bladder, just inside the bladder neck. This appeared to be sessile, and it was obviously tumor. There was some surrounding erythema. The rest of the bladder showed some inflammatory changes with erythema, but no overt lesions were noted.

It appeared that this was a relatively lower grade lesion that I had expected. A bilateral retrograde pyelogram was then performed which revealed a probable cyst in the upper pole of the right kidney with no other intrinsic filling defects or distortion. The left collecting system appeared to be quite normal with no ureteral defects.

Using cup biopsy forceps, random biopsies were taken from the trigone, the right and left lateral bladder wall, and the posterior bladder wall. These were submitted separately.

At this point, an extensive transurethral resection of the lesion in the right superior lateral portion of the bladder wall was performed using a resectoscope. The base was carefully fulgurated, as was the surrounding area, and all bleeding was carefully controlled. This tissue was submitted as a separate specimen for pathologic evaluation.

A careful bimanual exam revealed no evidence of induration within the bladder wall or other pelvic abnormality.

The patient tolerated the procedure very well and was taken to the Recovery Room in good condition.

K.U. Bladd, MD