CHIEF COMPLAINT: Urinary retention.

SUBJECTIVE: The patient is a (XX)-year-old gentleman who presented approximately a week ago in urinary retention. He, at that time, had a Foley catheter placed and was discharged to home with the Foley bag to gravity drainage. He returns today for a voiding trial and was found to have a postvoid residual of approximately 830 mL. The patient has had a prior episode of urinary retention in the past, approximately four years ago, and was placed on Cardura at that time.

In addition, the patient states that his PSA, approximately four years ago, was in the level of around 4 or so; however, the patient never had his PSA followed up. He does report that he, in addition, has some difficulty with his urinary stream. He has nocturia approximately only one time per night and he does have occasional incontinence on doing heavy activity or stressful work. The patient denies any urinary tract infection or gross hematuria. His prior episode of urinary retention, four years ago, involved nearly 48 hours without voiding. Actually, the patient did have a prostate biopsy approximately four years ago, which was reportedly negative.

PAST MEDICAL HISTORY: The patient’s past medical history is remarkable for smoking and reactive airways disease requiring an inhaler. The patient has had a right inguinal hernia repair.

MEDICATIONS: Include generic Cardura 8 mg p.o. daily as well as albuterol inhaler, which he uses daily.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: Remarkable for approximately anywhere from 2-4 drinks per day as well as approximately one-half pack per day. He has over a 40-pack-year history of smoking.

FAMILY HISTORY: No significant family history.

OBJECTIVE: On physical exam, he is a pleasant male in no acute distress. Lungs are clear. Heart is regular. Abdomen is soft, nontender and nondistended. He has a well-healed scar in the right groin. His GU exam reveals a circumcised phallus, which is unremarkable. He has bilateral descended testicles, which are also unremarkable and no palpable masses and they are nontender. Rectal exam reveals a 2-3+ prostate.

ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman with a history of urinary retention and benign prostatic hypertrophy who now presents with a failed voiding trial. The plan is to discharge this patient to home again with the Foley catheter, which will remain indwelling until the time of his surgery. He will be, today, scheduled for a TURP since his benign prostatic hypertrophy has resulted in urinary retention refractory to medical therapy. His urinalysis and urine culture, which were checked when he had his Foley catheter placed, were negative. He will, today, undergo a PSA test as well as any preoperative blood work that may be required. He will return and we will see him in the next several weeks for his operation.

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Urology Operative / Surgical Sample #1

OPERATIONS PERFORMED:
1. Cystoscopy.
2. Right retrograde pyelogram.
3. Right ureteroscopy/flexible nephroscopy.
4. Laser lithotripsy.
5. Stone basket extraction.
6. Placement of double-J stent

DESCRIPTION OF OPERATION: After obtaining consent, the patient in the operating room was placed in supine position. General anesthesia was administered. He was placed in lithotomy position, prepped and draped in normal sterile fashion. He received preoperative antibiotics.
Using a 21-French scope and a 12- and 70-degree lens, endoscopy was performed. The urethra itself was normal. Prostatic urethra was normal. Bladder itself was normal. Ureteral orifices were orthotopic in position with normal configuration. No ischemic bladder abnormalities.

A guidewire was placed up the right ureter. Some resistance was noted in the proximal ureter. We then attempted ureteroscopy using a 6.4 French semirigid Olympus ureteroscope. We were unable to traverse through the intramural portion of the ureter. Using a 10 cm balloon-dilating catheter, we gradually dilated over the course of approximately 5 minutes to 12 atmospheres of pressure. Scope then was passed up into the proximal ureter. There was an area of inflammatory change. The stone had obviously migrated more proximally. About 2 cm later was ureteropelvic junction. In the upper pole calices, did not initially notice any stones. A second guidewire was placed up in the renal pelvis and the rigid scope removed.

Using a flexible ureteroscope, the stone was identified in the upper pole calix. Using 200-micron fiber and the holmium laser, the stone was fragmented into small pieces. Two passes were used and the two larger pieces removed and sent for stone analysis.

The ureteroscope was removed. A 6-French x 24 cm double-J stent was passed over the guidewire. This was placed in a standard fashion. Proximal coiled end identified by fluoroscopy, distal coil by direct vision. The bladder was emptied. Digital rectal exam showed no significant abnormalities. The patient tolerated the procedure well. A B&O suppository was placed. There were no apparent intraoperative complications.

Urology Operative / Surgical Sample #2

OPERATION: Right donor nephrectomy.

DESCRIPTION OF OPERATION: After induction of general anesthesia, the patient was placed in a supine position. The abdomen was sterilely prepped and draped in the usual sterile fashion. A right subcostal incision was made approximately two fingerbreadths below the costal margin and parallel to the costal margin. Incision was carried down through subcutaneous tissues until fascia was exposed. The fascia and muscle layers were then incised along the length of the skin incision and peritoneum was carefully entered. Electrocautery was used to control any bleeding. A Bookwalter self-retraining retractor was placed to aid the exposure.

The right colon was reflected medially out of harm’s way. There were some adhesions in the area of the liver bed and these were carefully taken down. The duodenum was mobilized medially in a general fashion. Gerota’s fascia was then entered medially over the renal vessels and the renal vessels were carefully exposed. The renal vein was dissected out to the vena cava and the renal artery was identified, and there was noted to be several branches under the cava; however, the artery was followed as far towards the aorta as necessary so that there would be a single artery for transplantation. The kidney was immobilized laterally, superiorly and inferiorly. The ureter was identified at the level of the lower pole of the kidney and was followed as far distally as possible where it was clipped and transacted. The fatty lymphatic tissue at the hilum was carefully ligated, clipped and transacted, leaving only renal vessels at the hilum.

Once the ureter seemed to be diuresing nicely, the renal artery was ligated on the aorta side and transected after which the renal vein was tied right at the vena cava and transected. The kidney was then delivered from the wound, where it was flushed at the back table and taken to an adjacent room for transplantation. Both renal vessels were doubly ligated with #0 silky Polydek suture. The renal bed was checked and no bleeding was found.

Renal bed was irrigated after which the incision was closed, reapproximating fascia in two layers of #1 PDS suture. The skin was closed using skin clips. Sterile dressings were applied. All sponge and instruments counts were correct. Estimated blood loss was less than 100 mL. The patient remained hemodynamically stable throughout the case and was taken to the recovery room in a stable condition.

Urology Operative / Surgical Sample #3

OPERATIONS:
1. Cystoscopy.
2. Insertion of left double-J stent.
3. Left extracorporeal shock-wave lithotripsy.

DESCRIPTION OF OPERATION: After induction of general anesthesia, the patient was placed in the modified lithotomy position. The genitalia were prepped and draped in the usual sterile fashion. A #21 French cystoscope was then inserted under camera vision. The urethra was slightly stenotic. The patient had a mild cystocele. The bladder mucosa was essentially unremarkable. The ureteral orifices were normal in position and configuration.

A guidewire was successfully placed up the left ureter, under fluoroscopic control, into the renal pelvis. A size 24 cm length, #6 French diameter double-J stent was then negotiated over the guidewire into good position in the upper pole collecting system, and the guidewire was then removed. The stent was seen curled in good position in the kidney and with slight redundancy in the bladder. The bladder was drained. The patient was then repositioned on the Storz lithotripsy table until the stone was in the focal point of the imaging system, and lithotripsy was commenced.

The patient was treated at a power setting of 7 and 8 for total of 2500 shocks delivered to all areas of the stone. There appeared to be good fragmentation of the stone. At the conclusion of procedure, the patient was removed from the lithotripsy table and transferred to the recovery room in stable condition. The procedure was well tolerated by the patient without complications.

Urology Operative / Surgical Sample #4

OPERATION: Cystoscopy and bladder biopsy.

DESCRIPTION OF OPERATION: The patient was placed in the dorsolithotomy position on a cystoscopy table, prepped and draped in the usual fashion. A #21 French cystoscope was passed through the urethra into the bladder. The urethra was normal. The bladder neck area, trigone, and ureteral orifice regions were edematous and inflamed. The rest of the vesical mucosa was unremarkable. The ureteral orifices were not identified. Using cold cup biopsy forceps, a biopsy specimen was taken from the edematous portion of the trigone. The area was cauterized. At the conclusion of the above, a vaginal inspection was performed. There was marked stenosis and atrophy of the vagina with a granulation-type tissue present. The rectum was unremarkable. The patient tolerated the procedure well and left the operating room in a satisfactory condition.

Urology Operative / Surgical Sample #5

OPERATIONS: Bilateral pelvic lymph node dissection and radial retropubic prostatectomy via Pfannenstiel incision and repair of left inguinal hernia with mesh.

DESCRIPTION OF OPERATION: The patient was brought to the surgical suite, after which the patient was given general endotracheal anesthesia. Once appropriate level was achieved, he was positioned over the kidney rest. The patient was then prepped giving access to the area below, beneath the umbilicus down to the mid thigh. Once this was done, the patient was draped in aseptic fashion. The proposed incision site was injected with 0.5% Marcaine with epinephrine. After this was completed, the Foley catheter was introduced into the bladder with 20 cc and the balloon and the Bookwalter retractor were set up appropriately.

After this was set up, the incision was made using a Pfannenstiel transverse approach. The muscles were divided and the perivesical space was opened. The iliac vessels were dissected out. The lymph nodes were removed from the right and left side. Ligatures were used in order to create hemostasis. After this was done and preservation of the nerves on each side, then the endopelvic fascia was incised. The lymph nodes were negative. The prostate was mobilized by freeing up the endopelvic fascia and the puboprostatic ligaments. A suture was placed at the junction of the bladder and the prostate for hemostasis. Then, the superficial dorsal veins were ligated using ligature. Dorsal vein ligature was placed. The McDougal clamp was placed underneath the dorsal vein complex and was ligated x3. CTX needle was used as safety in order to control any excessive bleeding. Then, the lateral pedicles were clamped with Allis clamp and suture ligatures were placed appropriately. Then, the dorsal vein complex was transected and the urethra was freed up by freeing up the neurovascular bundle around the urethra and passing a right angle underneath.

Once this was brought into the surgical field, we were able to dissect the urethra at the anterior wall and transect it to bring out the Foley catheter that was used as a self-retaining retractor. Once this was done, the posterior wall was transected and the rectourethralis muscles were freed up with blunt and sharp dissection. The prostate was brought back in a retrograde fashion. Hemostasis was controlled at this point and the seminal vessels were approached and were secured using hemoclips and ligatures appropriately. The vas were clipped appropriately. After this the pedicles were then secured and the prostate was removed in a circumferential fashion from the bladder neck. After it was removed, the margin of the bladder neck was sent for frozen section. Then, the bladder neck was everted with #3-0 chromic suture. The anastomotic sutures were then placed at the 3, 6, 9, and 12 o’clock positions using the Greenwald sound. Once these were placed appropriately and placed in the bladder, then these sutures were tied appropriately. A Jackson-Pratt was placed and a balloon catheter, #30 French, was placed in the bladder and this procedure was then focused on the left hernia.

After we dissected out the external ring, we were able to palpate the internal and external ring with finger palpation. We were able to place an external mesh plug into the external ring in order to block off the space. Once this was done, we then closed the external wall around the hernia by grasping the muscularis of the external oblique and its fascia plane enclosing it over the mesh. Once this was completed, we made sure that the cord was visible and unencumbered. Once this was completed, we check patency. The tract was closed and then the plug was affixed using #2-0 Vicryl suture. Once this was completed, the wound was copiously irrigated and the wound was closed with running PDS suture. Jackson-Pratt was secured with a nylon stitch and staples were placed in order to approximate the skin. The patient’s Foley catheter was irrigated. There were no clots. There was clear urine draining from the bladder. The patient was aroused, extubated, and carried to the recovery room in stable condition.

Urology Operative / Surgical Sample #6

OPERATION: Repair of fractured penis. Placement of Foley catheter.

PROCEDURE IN DETAIL: The patient was brought to the surgical suite. He had been given Rocephin prior to his being brought to the operating room, in the emergency room. The patient subsequently was given general endotracheal anesthesia secondary to his having eaten and this being an emergency procedure. After the patient was intubated, he was then positioned and shaved appropriately with emphasis to the penis. He was draped in an aseptic fashion. Then, the penis was blocked with 0.5% Marcaine circumferentially.

An incision was made, circumferentially, on the ventral aspect of the penis secondary to this being the area of the hematoma. Dissecting along the urethra, we placed a Foley catheter. Once we were able to remove the Buck’s fascia, there was a large amount of bright blood coming from the penis. This indicated the point of tear. We then repaired the tear with #3-0 PDS suture. After repairing the tear, we checked for leaks by placing a rubber band around the penis, injecting normal saline. There was no extravasation. There was good filling of the penis. At this point, the Buck’s fascia was repaired.

The skin was reapproximated first with the dartos being reapproximated with interrupted #3-0 PDS, and the skin approximated with a running #3-0 chromic suture. At the end of the procedure, a Coban dressing was placed around the penis with increased compression, and the Foley catheter was removed. The patient was aroused, extubated, and carried to the recovery room in stable condition.

Urology Operative / Surgical Sample #7

OPERATION: Cystoscopy with urethral dilation utilizing both filiform and van Buren sounds.

DESCRIPTION OF OPERATION: After the patient was anesthetized, he was placed in the lithotomy position. The penis, scrotum and surrounding areas were prepped with Betadine solution and draped with sterile drapes. Urethral stenosis was present and this was dilated to a #24 French sound. A #17 French cystourethroscope was passed past the urethral meatus and a marked stricture was encountered approximately 7 cm from the urethral meatus. A filiform was inserted through the scope but I was unable to pull it out of the scope, so therefore, the scope was removed and the filiform was eventually past the stricture and advanced up into the urinary bladder. The stricture was then dilated with followers from a #8 to #18 French. The filiform and followers were then removed, and the urethra was then progressively dilated utilizing van Buren sounds, and it was dilated to a #30 French sound. The cystourethroscope was then reinserted and was advanced easily into the bladder. The examination of the bladder showed chronic cystitis with marked trabeculations, early cellules and early diverticuli. Prostate gland was essentially normal. The stricture was dilated and again was approximately 7 cm from the meatus and was below the external sphincter. Urinary bladder was then drained by means of the cystoscope. A rectal examination of the prostate gland was then performed and showed no signs of enlargement or nodularity. The patient was then returned to the recovery room in satisfactory condition.

Urology Operative / Surgical Sample #8

PROCEDURE PERFORMED: Right ureteroscopy and stone extraction.

PROCEDURE IN DETAIL: After informed consent, the patient was brought back to the operating room. She was placed on the table in supine position. She was sedated. A laryngeal mask airway (LMA) was placed. After adequate general anesthesia, she was then placed in lithotomy, prepped and draped in the usual fashion. Cystoscopy reveals that there are some stone fragments visible in the bladder, perhaps she has passed off some of the previously mentioned stones. A Pollack catheter was inserted in the right ureteral orifice. A retrograde pyelogram confirms that there is an approximately 6 mm stone in the right distal ureter. There are no other stones seen on the right. The right system is noted to be quite dilated. A guidewire is passed up to the renal pelvis. Rigid ureteroscopy reveals a stone in the distal ureter, which is ensnared in a basket and removed without difficulty. The rigid ureteroscope was advanced all the way into the renal pelvis. There are no further stones seen. The flexible ureteroscope was also used to examine the right intrarenal pelvis. There are no further stones seen. All instruments and guidewires are therefore removed. The rigid ureteroscope was also passed up to the left side where there are some stone fragments seen in the proximal ureter, which are irrigated out of the collecting system. There are no further abnormalities noted. The patient’s bladder was then drained. All instruments and guidewires are removed. She was then taken out of lithotomy, awakened and extubated without difficulty, and taken back to the recovery room awake and in a satisfactory condition.

Urology Operative / Surgical Sample #9

PROCEDURES PERFORMED:
1. Needle biopsies of the prostate.
2. Cystoscopy.

PROCEDURE IN DETAIL: The patient was brought to the operating room and placed on the operating room table in the supine position. After induction of adequate anesthesia, the patient was placed in dorsolithotomy position. The lower abdomen and genitalia were prepped and draped in the usual sterile manner. After instillation of 40 mL of Betadine per rectum, digitally guided biopsies were taken about the right and left lobes of the prostate using the Biopty gun. Once adequate samples had been obtained, the patient’s lower abdomen and genitalia were prepped and draped in the usual sterile manner. Cystopanendoscopy was performed using the rigid 21-French cystoscope sheath with 30- and 70-degree lenses. The prostate was found to be roughly 4 cm in length and completely occlusive. The bladder itself was 2+ trabeculated. There were no tumors or cellules noted. There was no evidence of any diverticular formation. Clear efflux of urine was noted from both orifices, which were well away from the bladder neck. At the time of cystoscopy, there was no evidence of any bleeding from the prostate. Therefore, no cauterization was required. At the conclusion of the procedure, a 16-French 5 cc Foley catheter was passed into the bladder without any difficulty. The balloon was inflated and the catheter attached to sterile drainage. The patient tolerated the procedure well and was transported in a stable condition to recovery.

Urology Operative / Surgical Sample #10

OPERATIONS:
1. Palladium-103 seed implantation.
2. Cystoscopy.

DESCRIPTION OF OPERATION: The patient was placed in the exaggerative dorsolithotomy position on the operating table, prepped and draped in the usual fashion. An ultrasound transducer was inserted into the rectum. The prostate was visualized on the monitor. Under ultrasonic and fluoroscopic guidance, 61 Palladium-103 seeds were implanted percutaneously through the perineum into the prostate. At the conclusion of the implantation, a cystoscopic examination was performed by passing a #21 French cystoscope through the urethra and into the bladder. The anterior urethra was normal. The prostatic urethra was previously resected. The vesical mucosa was unremarkable. At the conclusion of the procedure, the patient returned to the recovery room in satisfactory condition.

Urology Operative / Surgical Sample #11

OPERATION: Cystourethroscopy and exchange of bilateral ureteral stents.

PROCEDURE IN DETAIL: The patient was premedicated and brought to the operating room. General anesthesia was administered. The patient was placed in the lithotomy position, prepared with Betadine and draped in a sterile manner.

Cystoscopy was carried out with a #21 French cystoscope sheath and 12- and 70-degree lenses. The instrument was assembled, passed to the bladder, and the findings are as above. The grasping forceps was now used and the tip of the left ureteral stent was now first grasped and pulled out through the urethral meatus.

A 0.035 sensor guidewire was now advanced under fluoroscopy into the left kidney. The stent was then removed and a second stent of #6 French, 26 cm Polaris was inserted in proper position.

Similar procedure was carried out on the other side after which the bladder was cleared of its debris. Some stone fragments were present and were also cleared. The bladder was then drained with an #18 French Foley catheter, and the patient was taken to the recovery room in good condition.

Urology Operative / Surgical Sample #12

OPERATION: Left hydrocelectomy.

DETAILS OF OPERATION: The patient was brought to the operating room and placed in the supine position. After induction of general anesthesia, the genitals were prepped and draped in the usual fashion. A scalpel was used to make a transverse incision over the left hemiscrotum; this measured approximately 4 cm in length. The incision was carried down through the various connective layers using Metzenbaum scissors and pickups until the hydrocele was encountered. Bleeding was controlled using electrocauterization where necessary. The hydrocele sac was then bluntly freed up from the surrounding connective tissue and brought out through the incision. The various tissue layers were peeled back over the hydrocele sac using a gauze pad. Following this, a stab wound was made into the hydrocele sac and clear yellow fluid was then evacuated. The hydrocele sac was then opened up using Metzenbaum scissors. Care was taken to avoid the testicle, epididymis, and the surrounding cord structures. The testicle and epididymis appeared normal. The hydrocele sac was then excised using Metzenbaum scissors leaving approximately a 1 to 1.5 cm rim around the testicle. This was sent out separately to pathology. Bleeding was once again controlled using electrocauterization where necessary. A 3-0 chromic was then used to do a running suture along the entire cut edge of the hydrocele sac. After assuring that there was no other intrascrotal bleeding, the testicle was then placed back into the scrotum in the correct anatomical position. Light fulguration of some skin edges that were oozing was performed. Subcutaneous connective tissue was then reapproximated using 3-0 chromic simple interrupted sutures, and skin was closed using 3-0 chromic simple interrupted sutures as well. The wound was sterilely cleansed, dried, covered with bacitracin ointment, Telfa, fluff dressing, and scrotal support.

The patient tolerated the procedure well and without complications. He was brought to the recovery room in stable condition.

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