mnowitzke
New
OPERATIVE NOTE
*
DATE OF SERVICE: 2/21/18
*
PREOPERATIVE DIAGNOSIS: bilateral ureteroileal obstruction and hydronephrosis
POSTOPERATIVE DIAGNOSIS: bilateral ureteroilieal anastamotic stricture and hydronephrosis
*
PROCEDURE: bilateral percutaneous renal access and tract dilation, ileoscopy, retrograde and antegrade pyelogram, establishment of percutaneous renal access and tract dilation, bilateral rigid nephroscopy, bilateral flexible ureteroscopy, right retrograde nephroureteral stent and ureteroileal anastamotic dilation
*
SURGEON: MD
ASSISTANT: MD
*
ANESTHESIA: General
ESTIMATED BLOOD LOSS: 100 ml
INTRAVENOUS FLUIDS: 2200 ml crystalloid
*
DRAINS AND TUBES: 6 fr nephrostomy tube placed as right indwelling single J stent, string attached
SPECIMENS: right and left ureteral Urine for cytology; right ureteroileal stricture brush biopsy
*
SIGNIFICANT FINDINGS: bilateral ureteroileal anastamotic stricture, completely obliterative on left side
*
OPERATIVE INDICADTION: xxxxxx is a 68 y.o. male, Body mass index is 24.8 kg/(m^2)., with a h/o muscle invasive bladder CA and s/p chemoradiation therapy who underwent robot-assisted radical cystoprostatectomy, ureteroileal conduit urinary diversion, extended bilateral pelvic lymphadenectomy, bilateral ureteral stent placement with Dr on 11/22/17. Complicated by pelvic fluid collection, sepsis and b/l HDN with uretero-ileal anastomotic stricture, s/p bilateral percuatneous nephrosotomy tube placement ~ 6 weeks ago. He presented today for evaluation of cause of ureteral obstruction. The risks, benefits and alternatives were discussed in detail and the patient wished to proceed.
*
PROCEDURE:
After fully informed, voluntary consent was obtained, the patient was transported to the operating room and placed supine. A critical pause was done to confirm correct patient, procedure and surgical site. Following induction of anesthesia, the patient was repositioned in the prone position and prepped and draped in the usual sterile fashion. A pre-procedural time-out was taken to again confirm correct patient, procedure and surgical site.
*
With the aid antegarde nephrostogram, percutaneous access to the right kidney was obtained with 18G diamond tipped needle, through the lower right posterior calyx, below the 12th rib. Return of urine confirmed proper access. Next a guidewire was passed through the needle into the collecting system and was visualized on fluoroscopy. The skin was then incised to accommodate renal dilators. Next a 24Fr balloon renal dilator was used to create the percutaneous tract and overlying sheath was advanced to the collecting system. The rigid nephroscope was inserted through the sheath, and renoscopy revealed the collecting system and no tumors were seen. A wire was then advanced through the nephroscope and seen to be headed down the ureter. The nephroscope was removed, leaving the wire in place, and a flexible nephroscope was then advanced over the wire. We were able to visualize the distal ureter and there was a noted stricture with a small pinpoint opening, and we were able to pass a wire through the opening. At this point, a second cystoscope was set up and passed through the patient's ileal conduit. After multiple attempts with multiple different wires, were were able to pass the wire through the anastomosis and into the ileal conduit, and out the conduit for through and through access. A 21F balloon dilator was then used to dilate the ureteroileal anastomosis. Brush biopsy was sent from the strictured area. No suspicous lesions were noted here. Adequate dilation was confirmed via cystoscopy and fluoroscopy. Next a 25cm, 8.5F nephroureteral tube was advanced in retrograde fashion with curl formed in right renal pelvis and drainage tube exiting out the ileal conduit. retrograde pyelogram confirmed proper position. This curl was then confirmed using direct visualization. The end of the nephrostomy tube was then protruding from the ileal conduit with a string attached. The original nephrostomy tube was then removed. All wires were removed from the system.
*
At this point, attention was turned to the left kidney. With the aid of biplanar fluoroscopy and antegrade pyelogram, percutaneous access to the left kidney was obtained with 18G diamond tipped needle, through the lower right posterior calyx, below the 12th rib. Return of urine confirmed proper access. Next a guidewire was passed through the needle into the collecting system and was visualized on fluoroscopy. The skin was then incised to accommodate renal dilators. Next a 24Fr balloon renal dilator was used to create the percutaneous tract and overlying sheath was advanced to the collecting system. The rigid nephroscope was inserted through the sheath, and renoscopy revealed the collecting system with no tumors seen. A wire was then advanced through the nephroscope and see to be headed down the ureter. The nephroscope was removed, leaving the wire in place, and a flexible cystoscope was then advanced over the wire. We were able to visualize the distal ureter and there was a stricture noted with an apparent blind end to the ureter. No contrast would pass the blind ending segment, and no contrast communicated with the ileal conduit. There was no visible opening. Fluorosocopy was performed which did not reveal any contrast filling into the ileal conduit. At this point, a second cystoscope was set up and passed through the patient's ileal conduit. Despite multiple attempts with multiple different wires, were were unable to pass the wire through the anastomosis and into the ileal conduit. At this point, the wires and cystoscopes were removed. The original nephrostomy access on the left side was left in place. The renal access sites were then closed with monocryl in simple buried fashion. The patient was then turned back to the supine position. The ostomy appliance was then replaced.
**
The patient tolerated the procedure well, was awakened from anesthesia, and taken to the recovery room in stable condition. There were no apparent complications.
I have these codes I chose, but I'm not too sure.
50432
52332
52351
74420
50395 (59)
74425 (59)
50430 (59)
Thank you!
*
DATE OF SERVICE: 2/21/18
*
PREOPERATIVE DIAGNOSIS: bilateral ureteroileal obstruction and hydronephrosis
POSTOPERATIVE DIAGNOSIS: bilateral ureteroilieal anastamotic stricture and hydronephrosis
*
PROCEDURE: bilateral percutaneous renal access and tract dilation, ileoscopy, retrograde and antegrade pyelogram, establishment of percutaneous renal access and tract dilation, bilateral rigid nephroscopy, bilateral flexible ureteroscopy, right retrograde nephroureteral stent and ureteroileal anastamotic dilation
*
SURGEON: MD
ASSISTANT: MD
*
ANESTHESIA: General
ESTIMATED BLOOD LOSS: 100 ml
INTRAVENOUS FLUIDS: 2200 ml crystalloid
*
DRAINS AND TUBES: 6 fr nephrostomy tube placed as right indwelling single J stent, string attached
SPECIMENS: right and left ureteral Urine for cytology; right ureteroileal stricture brush biopsy
*
SIGNIFICANT FINDINGS: bilateral ureteroileal anastamotic stricture, completely obliterative on left side
*
OPERATIVE INDICADTION: xxxxxx is a 68 y.o. male, Body mass index is 24.8 kg/(m^2)., with a h/o muscle invasive bladder CA and s/p chemoradiation therapy who underwent robot-assisted radical cystoprostatectomy, ureteroileal conduit urinary diversion, extended bilateral pelvic lymphadenectomy, bilateral ureteral stent placement with Dr on 11/22/17. Complicated by pelvic fluid collection, sepsis and b/l HDN with uretero-ileal anastomotic stricture, s/p bilateral percuatneous nephrosotomy tube placement ~ 6 weeks ago. He presented today for evaluation of cause of ureteral obstruction. The risks, benefits and alternatives were discussed in detail and the patient wished to proceed.
*
PROCEDURE:
After fully informed, voluntary consent was obtained, the patient was transported to the operating room and placed supine. A critical pause was done to confirm correct patient, procedure and surgical site. Following induction of anesthesia, the patient was repositioned in the prone position and prepped and draped in the usual sterile fashion. A pre-procedural time-out was taken to again confirm correct patient, procedure and surgical site.
*
With the aid antegarde nephrostogram, percutaneous access to the right kidney was obtained with 18G diamond tipped needle, through the lower right posterior calyx, below the 12th rib. Return of urine confirmed proper access. Next a guidewire was passed through the needle into the collecting system and was visualized on fluoroscopy. The skin was then incised to accommodate renal dilators. Next a 24Fr balloon renal dilator was used to create the percutaneous tract and overlying sheath was advanced to the collecting system. The rigid nephroscope was inserted through the sheath, and renoscopy revealed the collecting system and no tumors were seen. A wire was then advanced through the nephroscope and seen to be headed down the ureter. The nephroscope was removed, leaving the wire in place, and a flexible nephroscope was then advanced over the wire. We were able to visualize the distal ureter and there was a noted stricture with a small pinpoint opening, and we were able to pass a wire through the opening. At this point, a second cystoscope was set up and passed through the patient's ileal conduit. After multiple attempts with multiple different wires, were were able to pass the wire through the anastomosis and into the ileal conduit, and out the conduit for through and through access. A 21F balloon dilator was then used to dilate the ureteroileal anastomosis. Brush biopsy was sent from the strictured area. No suspicous lesions were noted here. Adequate dilation was confirmed via cystoscopy and fluoroscopy. Next a 25cm, 8.5F nephroureteral tube was advanced in retrograde fashion with curl formed in right renal pelvis and drainage tube exiting out the ileal conduit. retrograde pyelogram confirmed proper position. This curl was then confirmed using direct visualization. The end of the nephrostomy tube was then protruding from the ileal conduit with a string attached. The original nephrostomy tube was then removed. All wires were removed from the system.
*
At this point, attention was turned to the left kidney. With the aid of biplanar fluoroscopy and antegrade pyelogram, percutaneous access to the left kidney was obtained with 18G diamond tipped needle, through the lower right posterior calyx, below the 12th rib. Return of urine confirmed proper access. Next a guidewire was passed through the needle into the collecting system and was visualized on fluoroscopy. The skin was then incised to accommodate renal dilators. Next a 24Fr balloon renal dilator was used to create the percutaneous tract and overlying sheath was advanced to the collecting system. The rigid nephroscope was inserted through the sheath, and renoscopy revealed the collecting system with no tumors seen. A wire was then advanced through the nephroscope and see to be headed down the ureter. The nephroscope was removed, leaving the wire in place, and a flexible cystoscope was then advanced over the wire. We were able to visualize the distal ureter and there was a stricture noted with an apparent blind end to the ureter. No contrast would pass the blind ending segment, and no contrast communicated with the ileal conduit. There was no visible opening. Fluorosocopy was performed which did not reveal any contrast filling into the ileal conduit. At this point, a second cystoscope was set up and passed through the patient's ileal conduit. Despite multiple attempts with multiple different wires, were were unable to pass the wire through the anastomosis and into the ileal conduit. At this point, the wires and cystoscopes were removed. The original nephrostomy access on the left side was left in place. The renal access sites were then closed with monocryl in simple buried fashion. The patient was then turned back to the supine position. The ostomy appliance was then replaced.
**
The patient tolerated the procedure well, was awakened from anesthesia, and taken to the recovery room in stable condition. There were no apparent complications.
I have these codes I chose, but I'm not too sure.
50432
52332
52351
74420
50395 (59)
74425 (59)
50430 (59)
Thank you!