TRANSURETHRAL RESECTION OF BLADDER TUMOR WITH CYSTOSCOPY & STENT PLACEMENT
PREOPERATIVE DIAGNOSES: (1) Acute renal failure. (2) Bilateral hydronephrosis. (3) Acute urinary retention.
POSTOPERATIVE DIAGNOSES: (1) Acute renal failure. (2) Bilateral hydronephrosis. (3) Acute urinary retention. (4) Plus left pyonephrosis and bilateral ureteral obstruction. (5) Severe cystitis and bladder calculi.
OPERATIONS PERFORMED: (1) Transurethral resection of bladder tumor. (2) Cystoscopy. (3) Bilateral ureteral stent placements.
SURGEON: George Washington, M.D.
ANESTHESIA GIVEN: Local monitored anesthesia care.
INTRAOPERATIVE FLUIDS: IV fluids 200 cc crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: 22-French three-way Foley catheter and 24 double-J stent in the right ureter, 26 double-J stent in the left ureter.
DISPOSITION: Back to floor.
INDICATIONS FOR PROCEDURE: The patient is an 80-year-old white male who presented with acute renal failure, bilateral hydronephrosis, and acute urinary retention. After Foley catheterization, his creatinine stabilized somewhat but did not return back to baseline. He continued to spike fevers despite being on broad spectrum antibiotics. No cultures ever grew. Given the fact that he continued to spike fevers and his creatinine remained above baseline, and that he had bilateral hydronephrosis, we took him to the cystoscopic suite for a cystoscopy and bilateral retrogrades, and possible stent placement.
DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room and was placed in the supine position. After the successful induction of local anesthesia and some mild sedation, the patient was placed in the dorsal lithotomy position and his perineum was prepped and draped in the usual sterile fashion.
Then using the 22-French panendoscope with the 30-degree lens, the scope was inserted through the urethra and into the bladder. His entire urethra was visualized and was normal to inspection. Upon entering the bladder, there was some diffuse, severe cystitis with diffuse calcifications of the entire bladder mucosa. This appeared to be a very bad chronic cystitis picture. Neither ureteral orifice was able to be identified. We then began removing sloughed mucosa and bladder calculi with the resectoscope loupe and with the Ellik evacuator. Once we had removed the vast majority of these calculi, we still could not identify the orifices. We then used the resectoscope loop to resect where we suspected that each orifice was. Methylene blue had been given. No methylene blue was seen in the bladder.
We eventually did resect down to where we could identify an orifice. The wire was passed and a 5-French open-ended catheter was passed up the left orifice. It was aspirated and a large amount of purulent material was obtained and sent for culture. The wire was repassed up this catheter and the catheter was removed and #6 26 double-J stent was placed. A similar procedure was done for the right ureter and a #6 24 double-J stent was placed in that ureter.
The patient tolerated the procedure well. The scope was removed and a 22-French three-way Foley catheter was inserted.
PREOPERATIVE DIAGNOSIS:Balanoposthitis, phimosis.
POSTOPERATIVE DIAGNOSIS:Phimosis with posthitis without balanitis.
PROCEDURE PERFORMED: Circumcision.
SURGEON: Randolph Randolph, M.D.
ANESTHESIA GIVEN: 30 cc of 0.25% Marcaine (plain) as a field block at the base and with a portion distributed at the frenulum; monitored anesthesia care and then general anesthesia with LMA.
SPECIMENS REMOVED: Fragments of foreskin.
ESTIMATED BLOOD LOSS: 25-50 cc.
CONDITION OF PATIENT: Satisfactory.
FINDINGS: The patient was found to have massive edema of the foreskin without any evidence of purulence. No inflammatory changes were noted involving the glans penis.
DESCRIPTION OF THE PROCEDURE: After satisfactory placement in a supine position, the patient was induced with deep sedation. This monitored anesthesia care was provided by Dr. Doviak and was maintained throughout the procedure. In an effort to make his job easier, I infiltrated the 30 cc of 0.25% Marcaine plain at about the base of the penis and at the area of the frenulum. The area was prepared with a thick jelly Betadine for good penetration and to keep the pubic hair away from the operative area. Dorsally, a straight clamp was passed across the edematous foreskin beginning at the level of the phimosis and the tissue was crushed. Along this relatively avascular line, the fine Metzenbaum scissors were used to divide the tissue to within about one centimeter of the glans. Similar incisions were made at three o'clock and nine o'clock and this produced wings of redundant markedly edematous penile skin. We were surprised to find no evidence of purulence and no inflammation of the glans penis nor the mucosa. A number of small bleeding points were noted around the shaft. These were clamped with fine hemostats and electrofulgurated. A few fine chromic sutures were placed to provide complete hemostasis. The cut edge of the mucosa and the skin was then reapproximated with interrupted vertical mattress and horizontal mattress sutures of 2-0 chromic. There being sufficient resolution of the bleeding and the swelling seemed to respond as well to gentle pressure, and the application of an antibiotic ointment, Xeroform gauze, and a circumferential gentle pressure dressing, the patient was taken to the recovery area in satisfactory condition.
I am not certain why this patient presented with this painful acute posthitis complicated by his phimosis. There was no evidence of drug usage and no evidence of insect bite or of other contact dermatitis. The patient will continue on cephalosporin and I am going to give him a few doses of an agent for anaerobic bacteria. There is nothing here to suggest Fournier's gangrene. The patient will be re-examined in the morning.
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