Cystoscopy and DJ stent removal / exchange

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

• burning and blood in urine for a day or two
• urinary infection and fever
• stent may be encrusted or stuck and need another procedure (laser, ureteroscopy or PCNL)
• stent may break or migrate during removal
• failure to pass a new stent in an exchange, and the need for a nephrostomy
• flank pain after removal from ureteric oedema
• urethral injury (rare)

Pre-operative details for this operation

1. Side of stent and date insertedcopy from the earlier operative note
2. Reason stent was placedafter URS / PCNL / pyeloplasty / obstruction / other
3. Stent details from earlier notesize (Fr), length (cm), make; tether left or not
4. PlanRemoval onlyExchange (remove and replace)Removal with retrograde pyelogram
5. X-ray KUB before procedurestent position, coils intact, encrustation or residual stone
6. Urine routine / cultureSterilePositive: organism, treated with (drug)
7. Renal functioncreatinine (important for long-term stents)

Anaesthesia and position

1. AnaesthesiaLocal anaesthetic urethral gelSpinalGeneralSedation + local
2. PositionLithotomySupine (flexible cystoscopy)
3. CystoscopeRigidFlexiblesize (Fr) and lens (0 / 30 / 70 degree)
4. Fluoroscopy (C-arm)UsedNot neededneeded for exchange
5. Irrigation fluidNormal salineSterile water / glycine (if cautery used)

Operative findings

1. Urethranormal / stricture / prostatic enlargement
2. Bladdermucosa, trabeculation, stones, tumour, oedema around the stent end
3. Distal coil of stentSeen in bladder, freeEncrustedNot seen (migrated up)
4. Stent on removalIntact, both coils completeEncrusted: siteBroken: fragment left
5. Opposite ureteric orificenormal / efflux seen

Procedure (steps)

1. Urethral preparationlubricant or lignocaine gel instilled; dilatation if needed (size)
2. Cystoscopysystematic check of urethra and whole bladder
3. Stent end graspedRigid grasping forcepsFlexible grasperRetractable lasso / basketPulled by tether (no cystoscopy)
4. Stent removedscope and grasper withdrawn together under vision; resistance or not
5. For exchange: guidewirestent end brought to meatus and wire passed through its lumen into the kidney, or safety wire placed alongside if orifice oedematous; wire type and size
6. For exchange: retrograde pyelogramoptional; findings
7. For exchange: new stentsize (Fr), length (cm), placed over the wire through the cystoscope or under fluoroscopy
8. For exchange: coil position confirmedupper coil in pelvis on fluoroscopy, lower coil in bladder on cystoscopy
9. Bladder emptiedYes

Closure, drains and dressing

1. Urethral catheterNoneFoley: size and reason
2. Tether on new stentNot leftLeft and fixed: date for removal
3. Urine at endclear / blood-tinged

Specimens and implants

1. Removed stentInspected and discardedEncrustation sent for stone analysisStent tip sent for culture
2. Urine for cultureSentNot sent
3. New stent (if exchange)make, size (Fr), length (cm), batch / lot number, sticker pasted, next exchange or removal date

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. Void before dischargerecord first void and colour of urine
2. Oral fluidsplenty of oral fluids for 24 hours
3. Analgesiafor flank pain after removal
4. Warning signsfever, severe flank pain, inability to pass urine: report at once
5. Stent card / registermark stent removed; for exchange, next due date written
6. Follow-up imagingUSG KUB after removal if the original problem needs it
7. Culture follow-upreview urine or stent-tip culture if sent

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