PCNL Operative Note Preoperative Diagnosis: Nephrolithiasis Postoperative Diagnosis: Same Procedure(s) Performed: 1. {Right/Left:18659} percutaneous nephrostolithotomy for stone burden {Blank multiple:19196:: "greater", "less"} than 2 cm 2. {Right/Left:18659} percutaneous renal access to establish nephrostomy tract 3. Cystoscopy with {Right/Left:18659} ureteral catheterization and retrograde pyelogram 4. Antegrade nephrostogram with nephrostomy tube placement 5. Simple Foley catheter placement 6. Intraoperative fluoroscopy with interpretation less than 1 hour Surgeons: @ORSURGPANEL@ Anesthesia: @ORANESSTAFF@ Endotracheal Ttube Indications for Surgery: @NAME@ is a @AGE@-year-old {Desc; male/female:11659} with a history of nephrolithiasis. The patient was evaluated and noted with a *** cm in diameter {Right/Left:18659} renal stone. The patient presents today for percutaneous treatment of {Right/Left:18659} kidney stone. The risks and benefits of the procedure were discussed with the patient who wishes to proceed. Operative Findings: Retrograde pyelogram demonstrated ***. Successful percutaneous access was obtained to the posterior {Blank multiple:19196:: "lower", "interpolar", "upper"} pole calix and treatment of the entirety of the stone burden. Antegrade nephrostogram post-treatment demonstrated no contrast extravasation. Successful placement of nephrostomy tube. Procedure Details: The patient was correctly identified in the preoperative holding area where written informed consent as well potential risks and complications were reviewed. The patient was brought back to the operative suite where a preinduction timeout was performed. After correct information was verified, general anesthesia was induced via endotracheal tube. The patient was then gently placed in prone position. Sequential compression devices were placed for VTE prophylaxis. The patient was prepped and draped in the usual sterile fashion and appropriate periprocedural antibiotics were administered. A second timeout was performed. At the beginning of the case, flexible cystoscope was performed per urethra with copious lubrication and normal saline irrigation running. The urethra and bladder appeared grossly normal. Turning our attention to the {Right/Left:18659} ureteral orifice, we gently cannulated the orifice with a sensor wire, which was advanced into the renal pelvis under fluoroscopic guidance. The cystoscope was removed and a 5 French open-ended catheter was advanced over the wire into the renal pelvis confirmed by fluoroscopy. The wire was removed. A 16 French Foley catheter was placed per urethra with return of urine with 10 mL's of water in the balloon. Next, we performed a retrograde pyelogram, which demonstrated findings as above. We elected to obtain {Blank multiple:19196:: "lower", "interpolar", "upper"} pole access and did so using an 18-gauge diamond-tipped Chiba needle using triangulation technique and fluoroscopic guidance. After placement of the access needle, a Glidewire was advanced into the kidney and manipulated down the patient's ureter with the assistance of the Kumpe catheter. This wire was subsequently switched to a sensor wire. Next, using a combination of catheters and dilators, we placed a second safety wire and then developed our percutaneous tract with the advancement of a 30 French x 20 cm Nephromax balloon dilator. After this, a 30 French sheath was advanced to the edge of the distal calyx on fluoroscopy. We then performed rigid nephroscopy with the lithotrite. Immediately upon entrance into the collecting system, we encountered the stone and we then proceeded to treat the stone with lithotripsy. After reaching the limit of the stone capable of being treated with the rigid scope, we then switched to flexible nephroscopy and removed additional stone using the laser and basket. We then switched to flexible ureteroscopy and visualized the entire ureter to the bladder in an antegrade fashion. At the conclusion of the procedure, we repeated flexible nephroscopy in the kidney as well and withdrew our sheath over our rigid nephroscope to the edge of renal parenchyma which did not reveal any residual stone fragments. At this point, we elected to leave our nephrostomy tube. We passed a 22 French Councill tip nephrostomy tube with indwelling Kumpe catheter over our wire down the patient's ureter without difficulty. Antegrade nephrostogram demonstrated complete filling of the entire renal collecting system with minimal contrast extravasation from the access tract and satisfactory placement of her nephrostomy tube in the renal pelvis. *** mL's of air was placed in the balloon and the nephrostomy tube was affixed to the patient's skin using a single 0 silk suture in an interrupted fashion. We then administered 10 mL's of 1% Lidocaine solution locally around the nephrostomy site and placed the nephrostomy tube to drainage. The site was then dressed in the usual gauze and tape dressing and the patient was carefully returned to supine position. The patient was awoken from anesthesia and taken to the recovery area. Estimated Blood Loss: *** Drains: 22 French council tip nephrostomy tube with indwelling Kumpe catheter. 16 French Foley catheter with 10 cc in the balloon. Both to drainage. Total IV Fluids: See anesthesia record Specimens: Stone for chemical analysis, gram stain and culture Implants: @ORIMPLANT3@ Complications: None Disposition: {Op note disposition:31782} Condition: {stable/unstable:60080} Post-Op Plan/Instructions: 1. Admit patient to Urology Service for routine postoperative care. 2. We will perform laboratory studies as well as obtain a CT scan postoperative day #1 to assess for any residual stone burden.