Cystoscopy and cystolitholapaxy

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• blood in the urine after the procedure
• urinary infection and fever
• stone pieces left behind and a repeat procedure
• change to a percutaneous or open operation if the stone cannot be broken or removed
• narrowing of the urethra (stricture) after long instrumentation
• catheter after the procedure
• stones may form again if the cause is not treated

Pre-operative details for this operation

1. Stone size and numberon X-ray KUB, ultrasound or CT; size in cm
2. Underlying causeNeurogenic bladder with long-term catheterNeurogenic bladder on intermittent self-catheterisationBladder outlet obstruction (BPH / stricture)Augmented bladder / neobladderForeign body, sling or meshNot known
3. Access routeUrethraExisting suprapubic tractMitrofanoff stoma only
4. Urine culture and antibiotic courseorganism and treatment before surgery
5. Urodynamics (neurogenic bladder)done or planned; key findings
6. Lithotripsy energy availablePneumaticLaserElectrohydraulicStone forceps only

Anaesthesia and position

1. AnaesthesiaGeneralSpinalLocal gel (flexible scope only)spinal cord injury at T6 or above: risk of autonomic dysreflexia; spinal removes it, general gives some control of blood pressure
2. PositionDorsal lithotomypressure points padded
3. Existing catheterremoved before start; type and size
4. Irrigation fluidNormal salineWater / glycine (if electrocautery used)in spinal cord injury at T6 or above, a distended bladder can trigger autonomic dysreflexia: do not over-fill, empty often

Operative findings

1. Urethranormal / stricture (site) / false passage; dilated to what size
2. Prostate and bladder necklobes, occlusion, bladder neck contracture
3. Bladder wallSmoothTrabeculatedTrabeculated with sacculi / diverticulum
4. Mucosainflammation, suspicious lesion (biopsied or not)
5. Stonesnumber, size, colour, hard or soft; foreign body or encrusted material
6. Ureteric orificesposition, efflux

Procedure (steps)

1. Painting, draping and lubricant gel into urethra
2. Urethral dilatationNot neededSerial sounds to 2 Fr above sheath size
3. Cystoscope passed under visionsheath size (Fr), lens (0 / 30 / 70 degree)
4. Systematic bladder surveytrigone and orifices, floor, posterior wall, lateral walls, dome (air bubble), anterior bladder neck
5. Stone fragmentationStone-crushing forceps (lithotrite)Pneumatic lithotripsyLaser lithotripsyElectrohydraulic lithotripsyprobe or fibre size, settings
6. Fragments removedgrasping forceps, evacuation by irrigation; approximate fragment count
7. Bladder rechecked for residual fragments and mucosal injury
8. Treatment of cause at the same sitting (if planned)e.g. TURP, stricture treatment, foreign body removal; describe separately
9. Catheter at endUrethral FoleySuprapubic catheterNot left (voiding patient)size, balloon volume, urine colour

Closure, drains and dressing

1. Final bladder drainagebladder emptied, urine colour
2. Catheter fixationstrapped to thigh / abdomen
3. Conversion (if needed)NonePercutaneousOpen cystolithotomyreason

Specimens and implants

1. Stone fragmentsSent for stone analysisNot sent
2. Bladder biopsy for HPENot takenTaken, site
3. ImplantsNone

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Urine colour and outputinform if heavy haematuria or catheter blocks
2. Cathetervoiding patient: remove at 24 to 48 hours for trial of void; long-term catheter patient: new catheter as per bladder plan
3. Antibioticas per culture; drug, dose, duration
4. Oral fluidsencourage oral fluids once awake
5. Analgesiaas on the drug chart
6. Bladder management reviewlong-term catheters carry a higher stone risk than intermittent self-catheterisation; discuss the plan
7. Follow-upstone analysis result; imaging for residual stone; treat the cause

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery