The report below describes a patient undergoing implantation of prostate brachytherapy. The entire procedure has been documented in detail, describing the step-by-step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.
Do you have a complicated surgery case that needs help with coding? RT Welter would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient-protected health information and organization identifiers. RT Welter will not use any medical records submitted in which PHI is not removed and protected.
– Click Here to Submit Redacted Surgery Case Study –
Patient:
DOB/Age/Sex: 75 years Male
Procedure & Operative Documents
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Prostate cancer.
POSTOPERATIVE DIAGNOSIS: Prostate cancer.
PROCEDURE PERFORMED: Implantation of prostate brachytherapy, Palladium-103 seeds.
INDICATION FOR PROCEDURE: The patient is 75 years old. He is diagnosed with biopsy-proven Gleason 3 + 4 equals 7 adenocarcinoma of the prostate. He has undergone external beam radiotherapy and neoadjuvant androgen deprivation therapy under the direction of Dr.DOE He now presents for brachytherapy boost. Risks, benefits, and alternatives of the procedure have been discussed in detail with the patient.
PROCEDURE AND FINDINGS: Informed consent was confirmed. The patient was brought to the operative suite. Time-out procedure performed. General anesthesia smoothly induced by anesthesia staff. The patient carefully placed in the dorsal lithotomy position. All pressure points appropriately padded. The genital area was sterilely prepped and draped in the usual fashion. A coude Foley catheter was placed. The bladder was drained. The balloon was inflated to 10 mL and 50 mL of sterile saline instilled in the bladder and the catheter was clamped. Dr.DOE then arranged the implant apparatus in conjunction with a transrectal ultrasound and matched is up to the pre-procedure treatment plan.
Subsequently, brachytherapy needles were placed for in the pre-planned locations. There were no complications doing seed placement. A total of 131 seeds were implanted. Fluoroscopy demonstrated appropriate seed distribution. Dr.DOE then placed SpaceOAR gel in the space between the rectum and the prostate without complication. The ultrasound probe was removed from the rectum. The Foley drained the bladder. There was a small minimal amount of blood from the drainage, which was anticipated. The patient was returned to supine position, woken by anesthesia staff, taken to the recovery room in stable condition. There were no apparent complications.
