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How would you code the procedures for this report?
PREOPERATIVE DIAGNOSIS:
1. Urethral stricture.
2. Multiple large bladder calculi.
POSTOPERATIVE DIAGNOSIS:
1. Urethral stricture.
2. Multiple large bladder calculi.
PROCEDURE: Cystoscopy with urethral dilatation; cystolithopaxy.
TYPE OF ANESTHESIA: General.
CATHETER: 22-French 10 cc two-way Foley.
DESCRIPTION OF PROCEDURE: Under general anesthesia the patient was placed in the lithotomy position. The skin of the perineum was prepped with Betadine and the patient was draped. An attempt was made to pass Van Buren sounds which was unsuccessful. The 17 cystoscope was then passed using saline for irrigation under direct vision, I was able to negotiate my way beyond an anterior false passage and down and up to a prostatic urethra. There was a high median bar that was relatively difficult to overcome. The bladder was emptied and filled with saline, inspection revealed three light-tan bladder calculi which were smooth and measured about 1.5 centimeters. The CyberWand was passed through the offset cystoscope. The stones were encountered and quite a bit of time was used trying to break them. This would make dense in the outside wall of the stone, but never broke a stone or reduced its size very much. The CyberWand was removed. The laser fiber to the Domier Holmium Laser was now passed. This was much more satisfactory and did start breaking the stones into smaller fragments. Occasionally would stop to suck out fragments using the Elllk evacuator. Finally no visible stones remained. This did cause a little damage to the trigone before the bladder with some bleeding. it was relatively ea now to pass a 22-French 10 cc Foley. The bladder was irrigated. We will watch in the recovery room, if the urine is not too dark he can go home with the catheter. In that event, we will see him back in three days for a “fill and full” and removal of his catheter, if it stays too bloody, we will substitute the catheter for a three-way and plan to keep him at least overnight.
He is given a prescription for Cipro 500 milligrams #14 one twice a day. Loroet Plus for pain.
PREOPERATIVE DIAGNOSIS:
1. Urethral stricture.
2. Multiple large bladder calculi.
POSTOPERATIVE DIAGNOSIS:
1. Urethral stricture.
2. Multiple large bladder calculi.
PROCEDURE: Cystoscopy with urethral dilatation; cystolithopaxy.
TYPE OF ANESTHESIA: General.
CATHETER: 22-French 10 cc two-way Foley.
DESCRIPTION OF PROCEDURE: Under general anesthesia the patient was placed in the lithotomy position. The skin of the perineum was prepped with Betadine and the patient was draped. An attempt was made to pass Van Buren sounds which was unsuccessful. The 17 cystoscope was then passed using saline for irrigation under direct vision, I was able to negotiate my way beyond an anterior false passage and down and up to a prostatic urethra. There was a high median bar that was relatively difficult to overcome. The bladder was emptied and filled with saline, inspection revealed three light-tan bladder calculi which were smooth and measured about 1.5 centimeters. The CyberWand was passed through the offset cystoscope. The stones were encountered and quite a bit of time was used trying to break them. This would make dense in the outside wall of the stone, but never broke a stone or reduced its size very much. The CyberWand was removed. The laser fiber to the Domier Holmium Laser was now passed. This was much more satisfactory and did start breaking the stones into smaller fragments. Occasionally would stop to suck out fragments using the Elllk evacuator. Finally no visible stones remained. This did cause a little damage to the trigone before the bladder with some bleeding. it was relatively ea now to pass a 22-French 10 cc Foley. The bladder was irrigated. We will watch in the recovery room, if the urine is not too dark he can go home with the catheter. In that event, we will see him back in three days for a “fill and full” and removal of his catheter, if it stays too bloody, we will substitute the catheter for a three-way and plan to keep him at least overnight.
He is given a prescription for Cipro 500 milligrams #14 one twice a day. Loroet Plus for pain.