Emmy Posted Thu 12th of March, 2020 13:30:25 PM
WE ARE SEEKING ADVICE FOR DX AND CPT PROCEDURES FOR ALL SURGEONS, CO-SURGEONS AND/OR RESIDENTS. SURGEON: BRANDY, MD
RESIDENT ASSISTANT: BAUER, MD
PREOPERATIVE DIAGNOSIS: Recent episodes of transient, brief, minimal gross hematuria, painless. History of bladder cancer treated 23 years ago.
History and Indication: The patient is a very pleasant 72-year-old man who under my care in 1996 underwent radical cystoprostatectomy, node dissection in orthotopic ileal neobladder for treatment of bladder cancer which was TCC high grade TA diffuse and carcinoma in situ. Over these past 23 years he has had excellent retention of normal renal function and quality of life and has perfect functioning of his neobladder. This spring he had an episode of hematuria, which was very minimal in amount and very brief in duration. It was painless. He had no evidence of urinary infection. Endoscopy of the pouch performed by me last spring when that episode occurred showed no fresh blood or clots or lesions in the neobladder. CT urogram at the time showed unremarkable upper urinary tracts. He recently returned to me with the new episode of transient brief hematuria. Again, there are no urinary infections. Flexible cystoscopy of the neobladder in the office revealed a tiny clustered papilliform like lesion which had fresh vessels and fresh blood on it. In the office, I thought this might represent tumor projecting from a right ureteral orifice. Underwent a new CT urogram, which again shows normal upper urinary tracks and collecting systems.
DESCRIPTION OF PROCEDURE: He was brought to the operating room today, placed supine on the table and given a general anesthetic by the anesthesiologist. The patient was then in lithotomy position. The genitalia were prepped and draped in a routine sterile manner. A 21 French cystoscope with a 30 degree lens was directed carefully into the neobladder under direct vision. His urethra was normal. There is no blood within the urethra and no erosions or lesions. The anastomosis of the urethra to the neobladder is smooth, healthy and intact. Inside the neobladder, the mucosa of the great majority of the neobladder has flattened, atrophied intestinal villi. On the uppermost portion of the bladder there remains an area where the normal appearance of small bowel mucosal villi is seen. These areas are free of any bleeding. The small clustered lesion that had been noted in the office cysto is again easily seen on the right side of the mid posterior portion. It is now evident today that this is not a tumor of the urolithium, nor is it protruding from a ureteral orifice. His right ureteral orifice was subsequently identified further posterior and further cephalad in the neobladder. That orifice has clear urine coming from it. An attempt to pass a flexible glidewire up the right ureter was unsuccessful and we elected not to persist in that effort. On the left superolateral part of the neobladder comma the left ureteral orifice was seen and it is a smooth rounded opening and has clear urine coming from it. On this left side, we were able to pass a glidewire over which we advanced in angiographic catheter to the left renal pelvis and with fluoroscopy we performed a left retrograde pyelogram which again confirms presence of a normal appearing left renal pelvis and left ureter. The glidewire and angiographic catheter were removed. We again focused our attention to the small clustered tiny vascularized papilliform form lesion that appears to be a Hemangioma on the surface of the intestinal neobladder mucosa . This was cauterized with a small tip bugbee cautery advanced through flexible cystoscope. After the initial attempts at the retrograde pyelograms, we had removed the rigid scope and proceed with flexible endoscopy. Several other bullous and rounded clustered lesions across the posterior wall of the neobladder were also cauterized. None of them appeared to have any recent or active bleeding. The only noted surface lesion that had prominent vessels in evident of having had recent bleed was the aforementioned finding that was fulgurated and cauterized. Several of the other lesions closest to it were also fulgurated. There were no pathologic specimens collected. The neobladder was drained and throughout the procedure had been periodically drained to avoid any overdistention. The patient's abdomen remained soft. All of the instruments were removed. An 18 French Foley catheter certain will be left overnight comma and the catheter maybe route removed by the patient at his home tomorrow. The patient was stable throughout the surgery and stable while awaiting transfer to the recovery area.