ESWL OPERATION DATE: 07/19/2019 PREOPERATIVE DIAGNOSIS: Bilateral ureteral calculi. POSTOPERATIVE DIAGNOSIS: Bilateral ureteral calculi. PROCEDURE: Right extracorporeal shock wave lithotripsy. PRIMARY SURGEON: Raju Thomas, MD, FACS ASSISTANT: Igor Voznesensky, MD ANESTHESIA: General. FINDINGS: Large upper right ureteral calculus fragmented well. COMPLICATIONS: None apparent. ESTIMATED BLOOD LOSS IN ML: None. SPECIMENS REMOVED: None. INDICATIONS FOR PROCEDURE: Mr. Eugene Lawson is a pleasant 56-year-old gentleman first seen at the VA ER when he was noted to have bilateral stones, requiring stenting. Of note, he underwent bilateral ureteral stent placement on 06/15/2019 for a 9-mm right mid ureteral stone and a 4-mm left proximal ureteral stone. Hounsfield units of the stones were approximately 530. He was counseled regarding various management options for his bilateral stone burden including medical management, attempted passage of the stone along stent with medical expulsive therapy, surgical intervention with ureteroscopy versus extracorporeal shockwave lithotripsy versus percutaneous nephrolithotripsy. Various risks, benefits, and potential complications of the procedure were discussed with the patient in detail. All questions were answered. Risks include but not limited to pain, infection, bleeding, scar, need for further surgical intervention, injury to surrounding structures likely urethra, bladder, ureters, kidney as well as surrounding blood vessels and nerves. The patient understood these risks and elected to proceed with extracorporeal shockwave lithotripsy with a staged procedure starting on the right side first. PROCEDURE IN DETAIL: After lengthy discussion of the indications for the procedure and potential complications as well as the risks and benefits, the patient's informed consent was obtained. He was seen in the perioperative unit and informed consent was verified. The risks and benefits of surgery were again discussed and the patient agreed to proceed. The patient was taken to the operative room and placed in the supine position on the lithotripsy table. Perioperative antibiotics of Ancef were given. The patient was then placed with the right flank aligned with a shock wave device and a spot KUB was taken to the line shockwave stone. After smooth and uneventful induction of anesthesia, lithotripter was started at 18 kilovolts at a rate of 90 shocks per second. We periodically took x-rays to assess resolution of stone. After total of 3000 shocks, an x-ray was obtained, which showed there appeared to be an adequate fragmentation of stone. Procedure was then concluded and the patient was awakened from anesthesia without issue. Dr.Raju Thomas was present and available for the entirety of the procedure and the procedure was performed on his VA time. DISPOSITION: The patient is to be discharged home today with followup at the VA scheduled in 2 weeks with pre-appointment KUB to be done.