Self Instructional Manual for Cancer Registrars - SEER - National ...

I
EXAMPLE
F3
REPORT
OF CYSTOSCOPY
Name Sammy Kidd Service Medicine Hospital No. 000021
Sex Male Age 56 Race White Date 1/14/91
Pre-operative Diagnosis: Carcinoma of the bladder
Surgeon K. U. Bladd, MD Assistant Surgeon Urie Sac, MD
Operative Diagnosis: Carcinoma of the bladder
Operation: Cystoscopy_ random biopsies of bladder_ bilateral retrograde pyelography:
TUR - primary bladder carcinoma
DESCRIPTION OF OPERATION: The patient was placed in the lithotomy position.
Under satisfactory general anesthesia, the cystoscope was passed into the bladder and
urine was sent for cytology. At this point, a careful evaluation of the bladder revealed a
relatively extensive localized exophytic lesion in the right superior lateral portion of the
bladder, just inside the bladder neck. This appeared to be sessile, and it was obviously
tumor. There was some surrounding erythema. The rest of the bladder showed some
inflammatory changes with erythema, but no overt lesions were noted.
It appeared that this was a relatively lower grade lesion than I had expected. A bilateral
retrograde pyelogram was then performed which revealed a probable cyst in the upper
pole of the right kidney with no other intrinsic filling defects or distortion. The left
collecting system appeared to be quite normal with no ureteral defects.
Using cup biopsy forceps, random biopsies were taken from the trigone, the right and
left lateral bladder wall, and the posterior bladder wall. These were submitted
separately.
At this point, an extensive transurethral resection of the lesion in the right superior
lateral portion of the bladder wall was performed using a resectoscope. The base was
carefully fulgurated, as was the surrounding area, and all bleeding was carefully
controlled. This tissue was submitted as a separate specimen for pathologic evaluation.
A careful bimanual exam revealed no evidence of induration within the bladder wall or
other pelvic abnormality.
The patient tolerated the procedure very well and was taken to the Recovery Room in
good condition.
K. U. Bladd, MD
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