Pre-op Diagnosis: Uric acid nephrolithiasis [N20.0]
Post-op Diagnosis: Left nephrolithiasis
Procedure(s): Left – URETEROSCOPY – Wound Class: Clean Contaminated – Incision Closure: No Incision / NA
Left – CYSTOSCOPY LITHOTRIPSY URETERAL and renal STONEs – Wound Class: Clean Contaminated – Incision Closure: No Incision / NA
Left – CYSTOSCOPY, URETERAL STENT EXCHANGE – Wound Class: Clean Contaminated – Incision Closure: No Incision / NA
Proc. Description(s) & CPT Code(s): URETEROSCOPY:
CYSTOSCOPY LITHOTRIPSY URETERAL STONE:
CYSTOSCOPY, URETERAL STENT EXCHANGE:
Anesthesia: General
Complications: None
Findings: The patient had a large stone burden in the left kidney. Another calyx was obstructed by a stone which was impacted into the kidney. Several of the stones were impacted into the kidney. There were lots of Randall’s plaques. A 270 micron laser fiber was used to break stones into small fragments measuring 1-3 mm in size. I had to use a 2nd fiber, this time a 200 micron fiber, as we were the 1st fiber out. All stone fragments appeared to be less than 3 mm in size.
Technique: After informed consent was obtained and IV Rocephin given, the patient was taken to the cystoscopy suite given a general anesthetic. He was placed in the dorsal lithotomy position with special attention to pad his extremities. A time-out was performed identifying the left side as the correct side. The patient’s groin and male genitalia were prepped and draped in a standard fashion. A scout KUB was obtained which showed calcifications overlying the left kidney as well as the stent to be in proper position. The 22 French cystoscope was passed through the urethra into the bladder and there were several fragments in the bladder which were removed and sent for stone analysis. The stent was then grasped with an alligator grasper and was brought to the meatus and then a motion wire was passed through the stent and up into the left kidney under fluoroscopy (left side). I then passed the semi-rigid ureteroscope through the urethra through the bladder into the ureter next to the wire. This passed through the distal and mid ureter but was unable to pass into the proximal ureter. I then assembled the digital flexible ureteroscope and I passed this through the urethra into the bladder under direct visualization and then into the left ureter next to the wire. This passed through the distal and mid ureter without difficulty and into the proximal ureter where stone fragment was encountered. At this time, I obtained a 270 micron laser fiber and passed this through the scope and then began breaking the stone up into multiple small fragments (lithotripsy exam). There were no other stone fragments in the ureter and I passed the scope all the way into the kidney. He had a large stone burden in all calices. We started at the mid pole calyx and broke numerous fragments up using dusting settings initially at 500 mJ and 25-50 hertz (frequency of shockwaves for lithotripsy). I eventually switched to fragmenting settings of 600 mJ and 20 hertz. I did the mid pole and lower pole and then eventually got to the upper pole calyx sees stones. There were multiple stones including 1 that was obstructing an upper pole calyx. Some of the fragments were imbedded into the mucosa of the kidney. We switched back to dusting settings and again all fragments appeared to be less than 3 mm in size. After an hour and a half, I elected to place a stent. The flexible digital ureteroscope was removed visualizing the ureter in its entirety. This was a rather atraumatic ureteroscopy. I then backloaded the wire into the cystoscope and repassed the cystoscope into the bladder and then passed a 6 French 26 cm double-J stent over the wire through the cystoscope and up into the left collecting system under direct visualization as well as fluoroscopy. Once the stent was in good position, the wire was removed there was a good curl in both the proximal distal ends of the stent. The bladder was drained and the cystoscope was removed. The plan will be for the patient to either return to the operating room in 2 weeks for another ureteroscopy or to have his stent removed in 2 weeks. I discussed operative findings with the patient’s sister.
ICD 10 and CPT codes:
N20.0 – Calculus of kidney
52356 CYSTO/URETERO W/LITHOTRIPSY and INDWELL STENT INSRT; (-LT Left side of body)
