Medical Specialty: Urology
Sample Name: Spermatocelectomy, Epididymectomy, & Vasectomy

PREOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,POSTOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,PROCEDURE PERFORMED:,1.  Left spermatocelectomy/epididymectomy.,2.  Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION:  ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  The patient also has family status complete and desired infertility.  The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was moved to the operating room.  A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach.  A #15 blade was used to make a transverse incision on the left hemiscrotum.  Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  The left testicle was examined.  A large spermatocele was noted.  Metzenbaum scissors were used to dissect the tissue around the left spermatocele.  Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  Electrocautery was used to confirm excellent hemostasis.  Attention was then turned to the more proximal aspect of the cord.  The vas deferens was palpated and dissected free with Metzenbaum scissors.  Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  Testicle was placed back in the scrotum in appropriate anatomic position.  The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  Attention was then turned to the right side.  The vas was palpated in the scrotum.  A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field.  A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  Two ends were hemostated with hemostats and divided with Metzenbaum scissors.  Lumen was coagulated with electrocautery.  Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  The patient was sent to Recovery in stable condition.  He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain.  The patient is to followup with Dr. X in seven days.
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DESCRIPTION: Left spermatocelectomy/epididymectomy and bilateral partial vasectomy.  Left spermatocele and family planning.

urology, partial vasectomy, spermatocele, epididymis, family planning, vas deferens, metzenbaum scissors, vasectomy, spermatocelectomy, epididymectomy, testicle, deferens, hemostats, electrocautery,

The described situation involves a surgical procedure with general anesthesia, which inherently carries some level of risk, including complications from anesthesia, surgical errors, or post-operative complications. However, the procedure was elective, meaning it was scheduled rather than an emergency, and the surgery and recovery are described as being completed without complications (e.g., estimated blood loss is minimal, and the patient is stable). While surgeries do hold a degree of risk, the absence of immediate complications and the elective nature reduce its stakes compared to emergency surgeries or those with immediate life-threatening conditions. The intention for the procedures—addressing discomfort from a spermatocele and achieving infertility for family planning—also focuses on quality of life and personal choice rather than urgent medical needs.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Urology
Sample Name: Scrotal Exploration

PREOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,POSTOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,PROCEDURE: , Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,ANESTHETIC:,  A 0.25% Marcaine local wound insufflation per surgeon, 15 mL of Toradol.,FINDINGS:,  Congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally.  No testis necrosis.,ESTIMATED BLOOD LOSS:,  5 mL.,FLUIDS RECEIVED: , 300 mL of crystalloid.,TUBES AND DRAINS:,  None.,SPECIMENS: , No tissues sent to pathology.,COUNTS:,  Sponges and needle counts were correct x2.,INDICATIONS OF OPERATION: , The patient is a 4-year-old boy with abrupt onset of left testicular pain.  He has had a history of similar onset.  Apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, I recommended an exploration.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified.  Once he was anesthetized, he was placed in supine position and sterilely prepped and draped.  Superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery.  Electrocautery was used for hemostasis.  The subdartos pouch was created with curved tenotomy scissors.  The tunica vaginalis was then delivered, incised, and testis was delivered.  The testis itself with a bell-clapper deformity.  There was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord.  The penis fascia was cauterized and subdartos pouch was created.  The upper aspect of fascia was then closed with pursestring suture of 4-0 chromic.  The testis was then placed into the scrotum in a proper orientation.  No tacking sutures within the testis itself were used.  The tunica vaginalis; however, was wrapped perfectly behind the back of the testis.  A similar procedure was performed on the right side.  Again, an appendix testis was cauterized.  No torsion was seen.  He also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture.  The local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% Marcaine.  The scrotal wall was then closed with subcuticular closure of #4-0 chromic.  Dermabond tissue adhesive was then used.  The patient tolerated the procedure well.  He was given IV Toradol and was taken to the recovery room in stable condition.
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DESCRIPTION: Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.

urology, de-torsed bilateral testes, testes fixation, bell clapper deformity, testicular torsion, subdartos pouch, tunica vaginalis, scrotal exploration, appendix testes, scrotal, testes, torsion, detorsion, insufflation, testis,

The situation involves a young child undergoing surgery for a suspected testicular torsion, a condition that can lead to testicular loss if not promptly and properly managed. While the surgery appears to have gone well with no actual torsion present at the time, the decision for surgical exploration and fixation was made to prevent future torsion and related complications. The stakes are moderately high because timely intervention is crucial for preserving testicular function and preventing necrosis, although the immediate risk was managed successfully here.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Urology
Sample Name: Prostatectomy - Robotic Radical Retropubic

PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1.  Radical retropubic prostatectomy, robotic assisted.,2.  Bladder suspension.,ANESTHESIA:,  General by intubation.,The patient understands his diagnosis, grade, stage and prognosis.  He understands this procedure, options to it and potential benefits from it.  He strongly wishes to proceed.  He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE:  ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion.  My camera ports were then placed in the standard fan array.  A camera port was placed in the midline above the umbilicus using the Hasson technique.  The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision.  My assistant was on the right.  The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis.  This nicely exposed the space of Retzius.  I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally.  The levator ani muscles were carefully dissected free from the prostate and pushed laterally.  Dissection was continued posteriorly toward the bundles and caudally to the apex.  The puboprostatic ligaments were then transected.  A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck.  The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound.  I then transected the posterior bladder neck down to the level of the ampullae of the vas.  The ampullae were mobilized and transected.  These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized.  Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply.  Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles.  I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water.  Hemostasis was found to be complete.  I then carried out a urethrovesical anastomosis.  This was accomplished with 3-0 Monocryl ligatures.  Two of these were tied together in the midline.  They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied.  A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation.  The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension.  This was done in hopes of obtaining early urinary control.  This was accomplished with 0 Vicryl ligatures.  One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis.  This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision.  A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk.  The camera port fascia was closed with running 0 Vicryl.  The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.
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DESCRIPTION: Radical retropubic prostatectomy, robotic assisted and bladder suspension.  Adenocarcinoma of the prostate.

urology, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy

The situation described involves a surgical procedure for adenocarcinoma of the prostate, which is a serious medical condition. The procedure itself carries significant risks such as bleeding, infection, impotence, and incontinence. Given the complexity of the surgery and the potential for life-altering complications, this situation is high-stakes. The patient's understanding and acceptance of the risks further emphasize the critical nature of the medical decision-making. Surgical procedures related to cancer are inherently high-stakes due to the potential impact on patient survival and quality of life.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma - H&P

HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes.  He has a PSA of 3.1, with a prostate gland size of 41 grams.  This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left.  He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant.  Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease.  Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting.  History of high blood pressure, as well.  He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:,  Penicillin.,SOCIAL HISTORY:,  He is not a smoker.  He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT:  Examination unremarkable.,Breasts:  Examination deferred.,Chest:  Clear to auscultation.,Cardiac:  Regular rate and rhythm.,Abdomen:  Soft and nontender.  He has no hernias.,Genitourinary:  There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities:  Examination unremarkable.,Neurologic:  Examination nonfocal.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Erectile dysfunction.,PLAN:  ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy.  The risks, benefits, and alternatives of this have been discussed.  He understands and asks that I proceed ahead.  We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.
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DESCRIPTION: Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical

urology, gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,

The information provided indicates a 62-year-old male diagnosed with a high Gleason score 8 adenocarcinoma of the prostate, which suggests a more aggressive cancer with potential for spreading. The patient is scheduled for significant surgical intervention including radical prostatectomy and bilateral pelvic lymphadenectomy. Prostate cancer, especially with a high Gleason score, is a serious condition that can significantly impact a patient's quality of life and survival if not treated promptly. The procedure itself carries typical surgical risks, which have been explained to the patient. Overall, the situation is high-stakes due to the nature of the cancer and the necessary surgical treatment plan. The decision regarding treatment has significant implications for the patient's health and well-being.


Medical Specialty: Urology
Sample Name: Pyeloplasty - Robotic

PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.
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DESCRIPTION: Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.

urology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,

The described procedure involves a robotic-assisted pyeloplasty and nephrolithotomy which are complex surgical operations on the urinary tract, specifically addressing an obstruction and removing kidney stones. The procedure is invasive, requiring anesthesia and precision in handling the crossing renal vessels and re-anastomosis of the ureter. Given these details, this situation involves significant medical risks such as complications from anesthesia, potential damage to surrounding tissues or organs, and the need for precise surgical technique to ensure no long-term damage or complications like infection, bleeding, or further obstruction. Additionally, renal procedures have the risk of impacting kidney function if complications arise. However, the procedure went smoothly with minimal estimated blood loss and no immediate complications reported. While not life-threatening in the standard execution, the inherent nature of the surgery and potential for severe complications classify this as a high-stakes situation.


Medical Specialty: Urology
Sample Name: Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:,  This is a 66-year-old gentleman who had an elevated PSA of 5.  His previous PSAs were in the 1 range.  TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden.  After extensive counseling, the patient elected for retropubic radical prostatectomy.  Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here.  Time out was taken to properly identify the patient and procedure going to be done.  General anesthesia was induced.  The patient was placed in the supine position.  The bed was flexed distant to the pubic area.  The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes.  The patient was then prepped and draped in normal sterile fashion.  Foley catheter was inserted sterilely in the field.  Preoperative antibiotics were given within 30 minutes of skin incision.  A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath.  The rectus sheath was then incised and the muscle was split in the middle.  Space of rectus sheath was then entered.  The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  The lymph node packet on the left side was then dissected.  This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally.  Care was taken to avoid injury to the nerves.  An accessory obturator vein was noted and was ligated.  The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  The bladder subsequently was retracted cephalad.  The prostate was then defatted up to the level of the endopelvic fascia.  The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide.  Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter.  The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  The urethra was subsequently divided in its entirety.  A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal.  Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia.  The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  Care was taken throughout the posterior dissection to preserve the integrity of the ureters.  The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  The bladder neck was then repaired using Vicryl in a tennis racquet fashion.  The rest of the mucosa was then everted.  The ureteral orifices and ureters were protected throughout the procedure.  At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  Hemostasis was then adequately obtained.  FloSeal was applied to the pelvis.  The bladder was then irrigated.  It was draining pink urine.  The wound was copiously irrigated.  The fascia was then closed using a #1 looped PDS.  The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion.  At this point, the procedure was terminated with no complications.  The patient was then extubated in the operating room and taken in stable condition to the PACU.  Please note that during the case about 3600 mL of blood was noted.  This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.
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DESCRIPTION: Open radical retropubic prostatectomy with bilateral lymph node dissection.

urology, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac vein, seminal vesicle, lymph node, foley catheter, dorsal venous, venous complex, bladder neck, dissection, prostatectomy, bladder, endopelvic, vicryl, catheter, vein, venous, fascia, dorsal, urethra,

The situation involves a major surgical procedure for the treatment of prostate cancer, specifically a radical prostatectomy with lymph node dissection. This is a high-stakes scenario due to several factors: the complexity of the surgery, the significant blood loss occurring during the procedure, and the overall critical nature of treating cancer. The surgical intervention aims to remove cancerous tissues and prevent metastasis, which is crucial for the patient's prognosis. The detailed description highlights the technical challenges and the measures taken to control bleeding, underscoring the critical importance of successfully performing the surgery to maintain patient safety and ensure optimal outcomes.


Medical Specialty: Urology
Sample Name: Prostate Fossa Irradiation - Followup

HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.  His urinary function had been stable until 2 days ago.  Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks).  His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional.  The bowel function is stable with occasional irritative hemorrhoidal symptoms.  He has had no hematochezia.  The PSA has been slowly rising in recent months.  This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days.  No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100.  He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds.  (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1.  NyQuil.,2.  Timolol eye drops.,3.  Aspirin.,4.  Advil.,5.  Zinc.,PHYSICAL EXAMINATION,GENERAL:  Pleasant, well-developed, gentleman in no acute distress.  Weight is 197 pounds.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular movement are intact.  Hearing is grossly intact.  The oral cavity is without thrush.  There is minor pharyngitis.,LYMPH NODES:  No palpable lymphadenopathy.,SKELETAL:  No focal skeletal tenderness.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION:  There are external hemorrhoids.  The prostate fossa is flat without suspicious nodularity.  There is no blood on the examining glove.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  Without focal deficit.,IMPRESSION:,  Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient.  He understands the probability that there may be residual cancer although the location is unknown.  For now there is no good evidence that early management affects the ultimate prognosis.  Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA.  I also suggested that he reestablish contact with Dr. X at his convenience.
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DESCRIPTION: The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.    Concerning slow ongoing rise in PSA.

The situation involves a patient who has had prostate cancer with a Gleason score of 8, which indicates a high-grade and aggressive cancer. The patient is now experiencing a slow rise in PSA levels post-treatment, which could suggest potential residual or returning cancer. Although there's an understanding that early management may not affect prognosis, the patient's situation still involves careful monitoring of cancer indicators, making it a significant concern in the context of potential cancer recurrence. However, there is no immediate life-threatening situation, as indicated by the stable health condition and Karnofsky score of 100. The patient is also not in acute distress and continues regular activities like full-time work.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma - 3

PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical.  He stated that he was in excellent health and led an active life.  His physical examination was normal for a man of his age.  Chest x-ray and chemical screening blood work were within normal limits.  His PSA was elevated.,IMAGING:,Chest x-ray:  Normal.,CT scan of abdomen and pelvis:  No abnormalities.,LABORATORY:,  PSA 14.6.,PROCEDURES: , Ultrasound guided sextant biopsy of prostate:  Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.,PATHOLOGY:  ,Prostate biopsy:  Left apex:  adenocarcinoma, moderately differentiated, Gleason's score 3 + 4 = 7/10.  Maximum linear extent in apex of tumor was 6 mm.  Left mid region prostate:  moderately differentiated adenocarcinoma, Gleason's 3 + 2 = 5/10.  Left base, right apex, and right mid-region and right base:  negative for carcinoma.,TREATMENT:,  The patient opted for low dose rate interstitial prostatic implants of I-125.  It was performed as an outpatient on 8/10.
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DESCRIPTION: Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.

urology, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma

This case involves a diagnosis of prostate cancer with an elevated PSA level, which is a significant medical concern. Prostate adenocarcinoma, especially with a Gleason score of 7, indicates an aggressive form of cancer that may require significant intervention. Treatment choices like radioactive implants are important decisions that can affect the patient's overall health and quality of life. The stakes are high because it involves managing a cancer diagnosis, deciding on treatment options, and monitoring the patient's response, all of which have profound implications for the patient's health and survival. However, it is not an immediate life-threatening emergency, hence not the highest stakes possible, but very significant nonetheless.


Medical Specialty: Urology
Sample Name: Penile Mass - Emergency Visit

CHIEF COMPLAINT: , "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was "trying to get some," meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,
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DESCRIPTION: Patient presents to the Emergency Department with complaint of a bleeding bump on his penis.

urology, bump on penis, bleeding bump, glans, urethral meatus, penile mass, emergency department, penis, penile, pedunculated, bump, mass,

The situation involves a visit to the Emergency Department due to a bleeding penile mass, which raises immediate concerns about potential complications, such as infection or malignancy. While the bleeding has been controlled and there is no acute distress or signs of systemic infection, the unusual nature and persistence of the mass necessitate further evaluation by a specialist. This indicates moderate urgency rather than an immediate life-threatening scenario. However, the potential for a serious underlying condition, like cancer or a sexually transmitted infection, elevates the stakes somewhat, as timely diagnosis and treatment are crucial for such conditions. Therefore, this situation is moderately high-stakes due to the potential for significant health implications if not addressed properly and promptly.


Medical Specialty: Urology
Sample Name: Penile Skin Bridges Excision

PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE:  ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS:  ,Same as above.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:,  No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION:  ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection.  Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified.  Once he was anesthetized, the caudal block was placed and IV antibiotics were given.  He was then placed in a supine position and sterilely prepped and draped.  Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors.  We removed the excessive skin on the shaft skin and on the glans itself.  We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic.  Electrocautery was used for hemostasis.  Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again.  IV Toradol was given at the end of procedure.  The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Excision of penile skin bridges about 2 cm in size.

urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile,

The procedure described, excision of penile skin bridges, is a standard surgical treatment for complications arising from circumcision. Given the minimal estimated blood loss and the use of general anesthesia, it is not a high-risk procedure. The child’s stable postoperative condition also indicates this is a routine surgical intervention. The stakes are not negligible, as any surgical procedure on a child involves some level of risk, but the stakes are not extremely high due to the routine nature and low complexity of the surgery.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma - 1

HISTORY:,  This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction.  After catheterization, the patient underwent cystoscopy on 4/13.  On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved.  Final diagnosis was adenocarcinoma of the prostate.  Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:,  None,PROCEDURES:,Cystoscopy:  Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate:  45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.
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DESCRIPTION: Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.

urology, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma,

The situation described involves a diagnosis of prostate adenocarcinoma in an elderly patient with a significant health issue (complete urinary obstruction) that required surgical intervention. Although the condition is serious, the patient's family has opted to decline further treatment due to his mental status and general debility. This decision reflects complex considerations involving healthcare, patient quality of life, and family dynamics. However, since there is no immediate life-threatening emergency and the family has made a decision regarding the course of treatment, the situation is not deemed extremely high-stakes. It involves managing the quality of life and care choices rather than an acute medical crisis.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma - 2

PHYSICAL EXAMINATION:,  This 71-year-old man went to his primary care physician for a routine physical.  His only complaints were nocturia times two and a gradual "slowing down" feeling.  The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L.  PSA was elevated.  The differential diagnosis for the visit was abnormal prostate, suggestive of CA.,IMAGING:  ,CT pelvis:  Irregular indentation of bladder.  Seminal vesicles enlarged.  Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus.  Impression:  prostatic malignancy with extracapsular extension and probable regional node metastasis.,Bone scan:  Negative for distant metastasis.,LABORATORY:,  PSA 32.1,PROCEDURES:,  Transrectal needle biopsy of prostate.  Pelvic lymphadenectomy and radical prostatectomy.,PATHOLOGY:  ,Prostate biopsy:  Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,Lymphadenectomy and prostatectomy:  Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa.  Therefore, the radical prostatectomy was canceled.  ,Final pathology diagnosis:  Pelvic lymphadenectomy; left obturator fossa, single negative lymph node.  Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes.  Largest involved node 1.5 cm.,TREATMENT: , Patient began external beam radiation therapy to the pelvis.
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DESCRIPTION: Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.

urology, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma

The situation involves a 71-year-old patient with prostate adenocarcinoma, a type of prostate cancer, which has potential metastatic involvement in regional lymph nodes. The diagnosis and treatment plan, including imaging, biopsy, and starting external beam radiation therapy, indicate that this is a significant medical issue with potential implications for the patient's health and quality of life. The urgency and complexity in managing cancer with potential spread elevate the stakes as it involves life-impacting decisions and treatments.


Medical Specialty: Urology
Sample Name: Penile Discharge

CHIEF COMPLAINT: , Penile discharge, infected-looking glans.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene.  The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge.  As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter.  However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump.  While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed.,REVIEW OF SYSTEMS: , Negative except as in the HPI.,PAST MEDICAL HISTORY: , Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia.,PAST SURGICAL HISTORY:  ,Right AKA,MEDICATIONS:,  Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine.,ALLERGIES: , PENICILLIN and ADHESIVE TAPE.,FAMILY HISTORY: , Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction.,SOCIAL HISTORY: , The patient lives alone.  He is unemployed, disabled.  He has history of tobacco use in the past.  He denies alcohol or drug abuse.,PHYSICAL EXAMINATION:,GENERAL:  A well-appearing African-American male lying comfortably in bed, in acute distress.,NECK:  Supple.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2, normal.,ABDOMEN:  Soft, nondistended, and nontender.,GENITOURINARY:  Penis is not circumcised.  Currently, indwelling Foley catheter in place.  On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue.  The proximal glans appeared pink.  The patient currently has indwelling Foley catheter and glans slightly tender to touch.  However, no purulent discharge was seen on compression of the glans.  Otherwise on palpation, no other deformity noticed.  Bilateral testes descended.  No palpable abnormality.  No evidence of infection in his perineal area.,EXTREMITIES:  Right AKA.,NEUROLOGIC:  Awake, alert, and oriented.  No sensory or motor deficit.,LABORATORY DATA: , I independently reviewed the lab work done on the patient.  The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative.  His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal.  CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13.,IMPRESSION: , A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans.  It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.  I think it is due to chronic ischemic changes.,RECOMMENDATIONS: , Our recommendation would be:,1.  To remove the Foley catheter.,2.  Local hygiene.,3.  Local application of bacitracin ointment.,4.  Antibiotic for urinary tract infection.,5.  Follow up as needed.  Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him.  If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled.
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DESCRIPTION: Penile discharge, infected-looking glans.  A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.

The situation involves a 67-year-old male with penile discharge and an infected-looking glans, accompanied by multiple comorbidities including end-stage renal disease, diabetes, and recent catheterization. These underlying conditions increase the risk of complications, and given the patient's recent hospitalization and ongoing medical management, timely and appropriate treatment is crucial to prevent further deterioration. Although immediate surgical intervention isn't required, neglecting these symptoms could lead to more severe health problems, such as infections, sepsis, or worsening ischemia. Therefore, the stakes are moderately high, as it requires careful monitoring and management to ensure the patient's condition does not worsen significantly.


Medical Specialty: Urology
Sample Name: Penile Injury

REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.
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DESCRIPTION: Penile injury and continuous bleeding from a penile laceration.

The situation involves an 18-year-old patient with a penile injury that is continuously bleeding due to self-infliction. This case is high-stakes due to several factors: there is active bleeding which can lead to significant blood loss, there is a foreign object retained which poses a risk of infection, and there is the potential for permanent damage to the penile tissue, which can affect future sexual function. Despite these factors, the patient is refusing immediate removal of the foreign object, complicating medical intervention and necessitating discussions about the potential for serious complications. This combination of medical urgency and the patient's current decision-making raises the stakes substantially.


Medical Specialty: Urology
Sample Name: Penile Cellulitis

CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.
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DESCRIPTION: The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.

urology, newborn circumcision, suprapubic fat pad, penile cellulitis, penile swelling, cellulitis, penis, penile, suprapubic, circumcision,

The situation involves serious medical conditions concerning a 16-month-old boy who developed penile cellulitis, including significant swelling, purulent discharge, and high fever following a circumcision. Staph infection is confirmed, and the situation requires hospitalization and careful monitoring. However, the patient's symptoms are improving with antibiotic treatment, and the condition is being actively managed. Given his age and the potential complications from a bacterial infection, this is a delicate medical situation but not life-threatening if properly treated. The stakes are significant due to the need for careful management and the young age of the patient, but it is not at the highest end of the stakes spectrum since the patient is showing improvement.


Medical Specialty: Urology
Sample Name: Overactive Bladder

REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder.  Her cystoscopy performed was unremarkable.  She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night.  No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms.  The patient had been previously on Ditropan and did not do nearly as well.  At this point, what we will try is a different medication.  Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted.  She has no other significant findings other than her overactive bladder, which had continued.  At this juncture what I would like to do is try a different anticholinergic medication.  She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan.  We will start Sanctura XR and we will follow up as scheduled.  Otherwise we will continue to follow her urinalysis over the next year or so.
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DESCRIPTION: Overactive bladder with microscopic hematuria.

urology, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive

The situation involves a patient with an overactive bladder and microscopic hematuria. While it requires medical attention and follow-up, it appears to be managed and monitored appropriately by the practitioner. There are no immediate life-threatening conditions noted, such as gross hematuria or obstructive symptoms, and there are no significant adverse effects from the medication. The situation involves a change in medication, which is part of regular treatment adjustments, not indicative of a crisis.


Medical Specialty: Urology
Sample Name: Orchiopexy & Hernia Repair

PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:,  Left undescended testis plus left inguinal hernia.,PROCEDURES:,  Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:,  A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:,  Sponge and needle counts were correct x2.,SPECIMENS,:  No tissues sent to Pathology.,ANESTHESIA:,  General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left.  The plan is for repair.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped.  A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue.  We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring.  We were able to dissect all the way up to the ring, but were unable to get the testis delivered.  We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia.  The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors.  The testis itself was quite high up in the upper canal.  We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors.  Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture.  We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length.  We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off.  We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum.  The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch.  The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture.  The testis was then placed into the scrotum in the proper orientation.  We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well.  We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure.  The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure.  The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.
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DESCRIPTION: Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.

urology, inguinal hernia repair, ilioinguinal nerve block, external oblique fascia, hernia repair, epididymal attachment, external ring, inguinal incision, scarpa fascia, cord length, inguinal hernia, nerve block, ilioinguinal nerve, undescended testis, testis, inguinal, fascia, hernia, dissected,

This is a surgical procedure involving a minor patient with an undescended testis and inguinal hernia. While surgical procedures always carry inherent risks, the description indicates the operation was performed successfully with minimal blood loss, no complications, and the patient was stable afterwards. Orchiopexy is a common urological procedure considered routine and typically not high-stakes unless complications occur, which is not the case here.


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Medical Specialty: Urology
Sample Name: Orchiopexy - Bilateral

PREOPERATIVE DIAGNOSIS:  ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.  Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses.  There is a hernia on the left side.  The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table.  General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically.  A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision.  An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia.  External ring was exposed with dissection as well.  The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal.  The testes were freed with dissection by removing cremasteric and spermatic fascia.  The hernia sac was separated from the cord, twisted and suture ligated at the internal ring.  Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring.  However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided.  This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel.  The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures.  The skin was approximated with interrupted #5-0 chromic catgut sutures.  Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good.  Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture.  Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion.  However, on this side, there was no inguinal hernia.  The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side.  The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure.  Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision.  The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition.  Instrument and sponge counts were correct.  There were no apparent complications.  Estimated blood loss was less than 20 to 30 mL.
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DESCRIPTION: Bilateral orchiopexy.  This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.

urology, bilateral orchiopexy, bilateral undescended testes, prentiss maneuver, subcutaneous tissues, internal ring, dartos pouch, scrotal incisions, undescended testes, spermatic cord, inguinal canal, testes, inguinally, orchiopexy, undescended, cord, vicryl, ultrasound, spermatic, canal,

Orchiopexy is a surgical procedure performed on children, often effectively resolving the issue of undescended testes (cryptorchidism), which, if left untreated, can have long-term consequences such as infertility and an increased risk of testicular cancer. Bilateral orchiopexy is considered routine in pediatric urological surgeries, with a high success rate and generally low risk when performed by experienced surgeons. This particular procedure was uncomplicated, and the child was reported to have awakened without apparent complications. The stakes are moderate due to the potential long-term health implications if untreated, but the direct surgical intervention itself carries a low immediate risk.


Medical Specialty: Urology
Sample Name: Orchiopexy & Herniorrhaphy

OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating room table.  The patient was prepped and draped in usual sterile fashion.  An incision was made in the groin crease overlying the internal ring.  This incision was about 1.5 cm in length.  The incision was carried down through the Scarpa's layer to the level of the external oblique.  This was opened along the direction of its fibers and carried down along the external spermatic fascia.  The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free.  A hernia sac was identified and the testicle was located.  Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring.  This was performed by incising the transversalis fascia circumferentially.  The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity.  Care was taken not to injure the testicular vessels.  Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance.  The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high.  This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum.  The testicle was viable.  This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum.  A small 1 cm incision was made in the anterior superior scrotal wall.  Dissection was carried down through the dartos layer.  A subdartos pouch was formed with blunt dissection.  The hemostat was then pushed against the tissues and this tissue was divided.  The hemostat was then passed through the incision.  A Crile hemostat was passed back up into the inguinal canal.  The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision.  The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle.  The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture.  Benzoin and a Steri-Strip were placed.  Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly.  This was done with 2 to 3 interrupted 3-0 silk sutures.  The external oblique was then closed with interrupted 3-0 silk suture.  The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch.  Benzoin and Steri-Strip were applied.  The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.
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DESCRIPTION: Orchiopexy & inguinal herniorrhaphy.

Orchiopexy & inguinal herniorrhaphy.

urology, orchiopexy, benzoin, crile hemostat, scarpa's layer, caudal block, cremasteric fascia, groin crease, hemiscrotum, iliopubic tract, inguinal canal, inguinal herniorrhaphy, intracuticular stitch, retroperitoneum, spermatic fascia, testicle, hernia sac, inguinal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The operative note describes a surgical procedure involving orchiopexy and inguinal herniorrhaphy, which are common urological surgeries. Although surgery inherently involves some level of risk, these procedures are well-established with standardized protocols and are generally considered low to moderate in terms of risk, especially when performed by experienced surgeons. The procedure was carried out successfully, with the patient in stable condition post-operation. Therefore, the stakes are not extremely high compared to more complex medical procedures.


Medical Specialty: Urology
Sample Name: Mini Laparotomy & Radical Retropubic Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,TITLE OF OPERATION:,  Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure.  The patient understands the treatment options and wishes to proceed.  He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion.  A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage.  The table was then placed in minimal flexed position.  A midline skin incision was then made from the umbilicus to the symphysis pubis.  It was carried down to the anterior rectus fascia into the pelvis proper.  Both obturator fossae were exposed.  Standard bilateral pelvic lymph node dissections were carried out.  The left side was approached first by myself.  The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally.  Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures.  The obturator nerve was visualized throughout and was not injured.  The right side was carried out by my assistant under my direct and constant supervision.  Again, the obturator nerve was visualized throughout and it was not injured.  Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself.  The  endopelvic fascia was opened bilaterally.  Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate.  A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level.  A sternal wire was then placed behind the dorsal vein complex which was sharply transected.  The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion.  When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions.  The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen.  The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected.  The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips.  Ampullae of the vas were mobilized, hemoclipped and transected.  The bladder neck was then developed using careful blunt and sharp dissection.  The prostate was then transected at the level of the bladder neck and sent for permanent specimen.  The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge.  The bladder neck was reconstructed in standard fashion.  It was closed using a running 2-0 Vicryl.  The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture.  At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger.  The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures.  When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck.  A new 20-French Foley catheter was brought in through the urethra into the bladder.  A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant.  The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated.  The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight.  The pelvis was also copiously irrigated with 2 liters of sterile water.  A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers.  The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular.  Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.
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DESCRIPTION: Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.  Adenocarcinoma of the prostate.

urology, mini-laparotomy, radical retropubic prostatectomy, pelvic lymph, pelvic lymph node dissection, cavermap, mini laparotomy, prostatectomy, bladder, intubation, adenocarcinoma, endopelvic, hemostasis, neck

The situation involves a surgical procedure to treat adenocarcinoma of the prostate, which is an operation for cancer. Surgical procedures, especially ones that involve cancer treatment, are inherently high-stakes due to the potential for complications, the impact on the patient's prognosis, and the possible risks mentioned such as bleeding, infection, incontinence, and more. Additionally, the success of the procedure can significantly affect the patient's quality of life and survival chances.


Medical Specialty: Urology
Sample Name: Orchiopexy

PREOPERATIVE DIAGNOSIS:,  Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General.  The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago.  The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.  The risks, benefits, and alternatives of the proposed procedure were discussed with the patient.  Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS:  ,The patient did receive Ancef antibiotics prior to the procedure.  He was then wheeled to the operative suite where a general anesthetic was administered.  He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure.  Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region.  The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery.  The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors.  This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord.  With this accomplished, the testis was then identified.  It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord.  Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens.  Weitlaner retractor was placed to provide further exposure.  There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl.  Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis.  Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment.  This was taken down to approximately the two-thirds length of the left scrotal compartment.  Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision.  A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment.  Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors.  A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision.  A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord.  With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis.  The sutures were then tied creating the orchiopexy.  The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures.  Once again hemostasis was maintained with Bovie electrocautery.  Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures.  External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad.  Once this was created, the created ring was inspected and there was adequate room for the cord.  There appeared to be no evidence of compression.  Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The patient had been injected with bupivacaine prior to closing the skin.  Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum.  He will follow up with Dr. X in 10 to 14 days.  Appointment will be made.
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DESCRIPTION: Left orchiopexy.  Ectopic left testis.   The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.

urology, pubic tubercle, ectopic testis, ectopic left testis, metzenbaum scissors, dartos pouch, bovie electrocautery, testis, orchiopexy, ectopic, scrotal, cord, dartos,

The situation involves a surgical procedure called orchiopexy to fix an ectopic left testis in a 16-year-old patient. While this involves a surgical process, the procedure itself is typically routine for urology specialists and is performed under controlled conditions. The stakes are higher than a non-invasive procedure, given that it involves surgery and general anesthesia, but it's not considered among the most high-risk surgical procedures.