Indication for procedure

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Indication for procedure: The patient has a known history of bladder tumor. She presents today for bladder biopsy and fulguration as well as instillation of Mitomycin C. She understands the treatment and risks and agrees by signed consent to the procedure. Procedure: The patient was taken to the operating room and induced under general anesthesia position . A 23 French cystourethroscope was advanced per orethra into the bladder. The bladder was carefully inspected, with no evidence of abnormalities noted other than two previously noted lesions for transitional cell carcinoma - one near the right ureteral orifice and one inferior to the left ureteral orifice. These lesions were biopsied and cauterized without difficulty. The lesions were noted at approximately 7-8 mm in size. A 20 French Foley catheter was inserted per urethra into the bladder without difficulty and noted to be draining clear urine. Next instillation of Mitomycin C wascompleted with a plan to keep in place for 45-50 minutes. The patient tolerated the procedure well. There were no complication. She was taken from the operating room to recovery in satisfactory condition. How would you report this procedure ?

Reference no: EM133625389

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