OT notes · Urology

Percutaneous nephrolithotomy (PCNL)

Usual anaesthesia
General (regional or spinal only in selected high-risk patients)
Position
Lithotomy for cystoscopy and ureteric catheter, then prone (or supine / modified supine)
Setting
elective

Operative note template for percutaneous nephrolithotomy, with a filled example for a prone PCNL for a left renal pelvic stone through a lower pole posterior calyx.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

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

  • bleeding needing transfusion or angioembolisation
  • fever and urosepsis
  • residual stone fragments and a second procedure
  • injury to pleura (pneumothorax, hydrothorax), especially with an access above the 12th rib
  • injury to colon, duodenum, liver or spleen (rare)
  • urine leak from the tract
  • DJ stent symptoms and the need for a second procedure to remove the stent
  • conversion to nephrostomy only and a staged procedure

Pre-operative details for this operation

  1. Side and stone details from CTside, size in cm, location (pelvis / calyx / staghorn), number, stone density if known
  2. Imaging reviewedNon-contrast CT KUBCT urogramIVUUSG + X-ray KUBnote retrorenal colon, enlarged liver or spleen, anomalies
  3. Urine cultureSterilePositive: organism, treated with (drug, days)
  4. Renal function and blood countscreatinine, Hb, platelets, coagulation
  5. Antiplatelets / anticoagulantsdrug and date stopped
  6. Blood grouped and cross-matchedgroup and units reserved

Anaesthesia and position

  1. AnaesthesiaGeneralSpinal / regional (state reason)
  2. First stage positionLithotomyProne split-legSupine with contralateral leg in lithotomy
  3. Ureteric cathetersize (5 or 6 Fr open-ended, or 7 Fr occlusion balloon), side, fixed to Foley
  4. Foley cathetersize (e.g. 16 Fr), balloon volume
  5. Main positionProne with chest and abdominal rollsSupine / modified supine (flank free)Lateralpressure points padded, arm positions
  6. Imaging for punctureFluoroscopy (C-arm)UltrasoundUltrasound + fluoroscopyrecord fluoroscopy time / dose if displayed
  7. Irrigation fluidNormal salinephysiological fluid only; volume used

Operative findings

  1. Retrograde pyelogramanatomy of pelvis and calyces, hydronephrosis, filling defects
  2. Aspirate at punctureClear urineTurbid urineFrank pus (sent for culture, tract not dilated)Blood
  3. Stonenumber, size, location, colour, hard / soft
  4. Pelvicalyceal systemmucosa, oedema at PUJ, perforation, any other lesion
  5. Stone clearance at endComplete on nephroscopy and fluoroscopyResidual fragments: site and size
  6. Antegrade study at endfree drainage down the ureter / extravasation

Procedure (steps)

  1. Cystoscopy and ureteric catheterisationscope size, side, catheter size, retrograde contrast
  2. Scout image saved before contrastYes
  3. Calyx puncturedLower pole posteriorMiddle (interpolar) posteriorUpper pole posteriorentry through the papilla
  4. Puncture site on skinSubcostal (below 12th rib)Supracostal (above 12th rib)Supracostal (above 11th rib)needle gauge (18 G diamond-tip), eye-of-needle / triangulation / USG
  5. Guidewiresworking wire (e.g. Amplatz super-stiff 0.035 inch) down the ureter or coiled in pelvis, safety wire
  6. Tract dilatationBalloonAmplatz serialAlken metal telescopicOne-shotfinal size in Fr, balloon pressure if used
  7. Access sheathtype and size in Fr (e.g. Amplatz 24 / 30 Fr, or mini 16.5/17.5 Fr)
  8. NephroscopyRigidRigid + flexiblescope size in Fr
  9. Stone fragmentationUltrasonicPneumatic (ballistic)Combined ultrasonic-pneumaticHolmium laserThulium fibre laserIntact extraction onlylaser settings if used (J, Hz)
  10. Fragment retrievalGrasperBasketSuction / flushed out
  11. Additional tractsnumber, calyx, sheath size, or none
  12. Check for residual stonesall calyces seen on nephroscopy; fluoroscopy compared with the scout image
  13. Antegrade contrast studyureter drains / fragments in ureter / extravasation
  14. Exit strategyNephrostomy tubeDJ stent (tubeless)Nephrostomy + DJ stentUreteric catheter onlyTotally tubeless

Closure, drains and dressing

  1. Nephrostomy tubetype (Malecot / pigtail / Foley / Councill), size in Fr, fixed with suture, open or clamped
  2. DJ stentsize in Fr and length in cm, antegrade or retrograde, upper coil position, lower coil in bladder on fluoroscopy, tether left or not
  3. Sheath removaltract inspected; for a supracostal tract, removed in held expiration
  4. Local infiltrationdrug, strength, volume (e.g. bupivacaine 0.5% with adrenaline)
  5. Skinsuture used around tube or for incision
  6. Chest fluoroscopy at end (supracostal access)NormalEffusion / pneumothorax: action takenNot applicable
  7. Urine in Foley at endclear / light pink / heavy haematuria

Specimens and implants

  1. Stone fragments for analysisSentNot sent
  2. Stone / renal pelvic urine for cultureSentNot sent
  3. DJ stentmake, size (Fr), length (cm), batch / lot number, sticker pasted, planned removal date
  4. Nephrostomy tubemake, type, size (Fr)

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. Vitals and haematuriapulse, BP, temperature; colour of urine in Foley and nephrostomy bag
  2. Nephrostomykeep open to bag, record output; plan for clamping and removal (day)
  3. Foley catheterkeep overnight, voiding trial next morning if no problems
  4. Chest X-rayif access was above the 12th rib
  5. Hb and creatinineon POD 1
  6. Fever watchblood and urine culture if temperature rises; review antibiotic
  7. Imaging for residual stoneX-ray KUB before stent removal; CT if stone was struvite
  8. DJ stent removaldate booked, written in discharge summary and told to the patient
  9. Stone analysis follow-upreport reviewed in OPD for prevention advice

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

Worked example

Fictional case: Mr. S.K., 45 years, left renal pelvic stone 2.6 x 1.8 cm on non-contrast CT KUB, mild hydronephrosis, sterile urine culture.

Case details

Date: 14/05/2026. Elective left PCNL. OT 4.

In OT 09:05. GA induction 09:15. Cystoscopy start 09:25. Puncture 09:50. Procedure ended 11:05.

Surgeon: Dr A. (3rd-year resident, Urology), did puncture and dilatation under supervision. Assistant: Dr B. Consultant: Dr C., scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E. Radiographer: Mr F.

Indication and pre-op

Left renal pelvic stone 2.6 x 1.8 cm, density 1100 HU, mild hydronephrosis. No retrorenal colon on CT.

Urine culture sterile. Creatinine 1.0 mg/dl. Hb 13.4 g/dl. Platelets and coagulation normal. Not on antiplatelets.

Blood group O positive, 2 units reserved.

Consent: general, procedure-specific (including DJ stent, second procedure, bleeding, chest complication) and anaesthesia consent taken in Marathi. Side marked.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:12, before start.

Anaesthesia and position

General anaesthesia with endotracheal tube.

Lithotomy: 22 Fr rigid cystoscopy, bladder normal. 6 Fr open-ended ureteric catheter placed in left ureter up to the kidney. 16 Fr Foley placed alongside and catheter tied to it.

Turned prone on chest and pelvic rolls, all pressure points padded, arms on arm boards. Left flank painted with povidone-iodine and draped. C-arm draped. Irrigation: normal saline.

Procedure

Scout image saved. Retrograde pyelogram: mild hydronephrosis, filling defect in the pelvis.

Lower pole posterior calyx selected. Subcostal puncture 1 cm below and medial to tip of 12th rib with 18 G diamond-tip needle, triangulation technique, in end-expiration. Clear urine aspirated.

0.035 inch hydrophilic guidewire passed and guided down the ureter with a 5 Fr angled catheter, exchanged for an Amplatz super-stiff working wire. Second (safety) wire placed through an 8/10 Fr coaxial dilator.

Tract dilated with a 24 Fr balloon to 20 atm. 24 Fr Amplatz sheath placed into the calyx under fluoroscopy.

Rigid nephroscopy: single yellow-brown hard stone about 2.5 cm in the pelvis. PUJ normal, no perforation.

Stone fragmented with combined ultrasonic-pneumatic lithotripter; fragments removed with suction and two-prong grasper.

Flexible nephroscopy of all calyces: no residual stone. Fluoroscopy compared with scout image: no residual shadow.

Antegrade contrast: free drainage down the ureter, no extravasation.

Closure

Left DJ stent 6 Fr x 26 cm placed antegrade over the working wire. Upper coil in the pelvis on nephroscopy, lower coil in bladder on fluoroscopy.

14 Fr pigtail (small-bore) nephrostomy placed through the tract over the wire, fixed to skin with a non-absorbable suture, left open to bag.

Tract site infiltrated with 10 ml bupivacaine 0.5% with adrenaline. Dressing applied.

Ureteric catheter removed. Foley retained, urine light pink.

Specimens and implants

Stone fragments sent for stone analysis. Renal pelvic urine sent for culture.

DJ stent: make ____, 6 Fr x 26 cm, lot no. ____, sticker pasted in the file. Planned removal: cystoscopic removal at about 1 week after X-ray KUB (date written in discharge summary).

End of procedure

Estimated blood loss 150 ml. No transfusion. Irrigation used: 9 L normal saline.

Mop, needle and instrument count correct.

No intra-operative complications.

Turned supine, extubated, shifted to recovery. Pulse 84/min, BP 126/80 mmHg, SpO2 99%.

Post-op orders

Pulse, BP, temperature 1-hourly for 6 hours, then 4-hourly. Record Foley and nephrostomy output and colour.

Nephrostomy open to bag. Clamp on POD 1 if urine clear, remove on POD 2 if no pain, fever or leak.

Foley till nephrostomy removal, then voiding trial.

Hb and creatinine on POD 1.

Report fever above 38 C at once: send blood and urine culture.

X-ray KUB before discharge to confirm stent position and no residual fragment.

Signature

Dr A., SR/JR-3, Urology. Reg. no. ________. 14/05/2026, 11:20.

Must document for this operation

  • Calyx punctured, puncture level in relation to the ribs, and tract size in French (Fr). A second-look procedure uses the same tract, and a supracostal tract changes the post-op chest check.
  • Aspirate at puncture (clear, turbid or pus) and whether cultures were sent. If fever or sepsis follows, the treating team needs the culture from the kidney, not only the bladder urine.
  • Stone clearance at the end, with the site and size of any residual fragment. This decides whether a second-look PCNL or other treatment is booked, and it is the main outcome of the operation.
  • Double-J (DJ) stent size, length, make, lot number and planned removal date. A forgotten stent encrusts and can cost the patient a kidney; the removal date must travel with the patient.
  • Nephrostomy tube type and size, and whether it was left open or clamped. The ward team needs this to manage output, clamping and removal.
  • Irrigation fluid used (normal saline) and approximate volume. Large volumes or a perforation raise the risk of fluid overload and are needed if the patient becomes unwell.
  • Any perforation, bleeding that stopped the operation, or chest complication. These change the post-op plan and must be disclosed and recorded for audit.

Common mistakes in these notes

  • Writing 'PCNL done, stone removed' with no calyx, tract size or clearance status.
  • Not recording the DJ stent length and removal date, so the stent is forgotten.
  • Not writing that the access was supracostal, so no chest X-ray is ordered.
  • Leaving out the irrigation fluid and volume.
  • Not noting that the stone was sent for analysis, so no one looks for the report.

Indian practice and paperwork

  • NABH asks that the batch and serial number of an implanted device be written in the patient's record, the OT master logbook and the discharge summary. A DJ stent left in the body should be treated this way: paste the sticker and copy the lot number. (NABH 5th ed., MOM.10(d))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Smith JA Jr, Howards SS, Preminger GM, Dmochowski RR, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 24, Percutaneous Renal Access (Shelton, Borofsky, Lingeman); Ch 25, Percutaneous Nephrolithotomy (Knudsen), pp. 210-232.
  • Smith AD, Preminger GM, Kavoussi LR, Badlani GH, eds. Smith's Textbook of Endourology. 4th ed. Wiley-Blackwell; 2019, Ch 12 Positioning for PCNL (p 202); Ch 13 PCNL Access Under Fluoroscopic Control; Ch 21 Dilation of the Nephrostomy Tract (Alken); Ch 25 Staghorns (p 314); Ch 36 Exit Strategies After PCNL (Bolton, Hennessey), pp. 202, 210-220, 275-284, 314, 427-440.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV adult (3 g if 120 kg or more), started within 60 min before incision. Table 2, urologic, clean with entry into urinary tract: cefazolin. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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