OT notes · Urology

Open ureterolithotomy / pyelolithotomy

Usual anaesthesia
General
Position
Flank (lateral decubitus, table flexed) for renal pelvis and upper ureter; supine for lower ureter
Setting
elective

Operative note template for open ureterolithotomy and open pyelolithotomy, with a filled example for a left upper ureteric stone removed through a flank incision with an antegrade DJ stent.

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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

  • urine leak from the ureter or pelvis and a longer drain time
  • narrowing (stricture) of the ureter later
  • stone pieces left behind needing another procedure
  • DJ stent discomfort and a second procedure to remove the stent
  • bleeding and transfusion
  • pneumothorax or pleural injury with a flank incision
  • wound pain, infection, hernia or flank bulge
  • narrowing at the pelvi-ureteric junction after pyelolithotomy

Pre-operative details for this operation

  1. OperationUreterolithotomyPyelolithotomyExtended pyelolithotomy
  2. Side and stone positionRenal pelvisUpper ureter (above iliac vessels)Lower ureter (below iliac vessels)vertebral level, size in cm
  3. Why open surgeryLow chance of success with ESWL / URS / PCNLFailed endoscopic treatmentEndoscopic equipment not availableCombined with another open procedure
  4. Recent imaging on the dayCT KUBX-ray KUBdate; stone has not moved
  5. Kidney functioncreatinine; DMSA / renogram if the kidney may be poorly functioning
  6. Renal pelvis type (pyelolithotomy)ExtrarenalIntrarenal (pyelolithotomy not suitable)
  7. Urine culture and antibiotic courseorganism, drug, days given before surgery

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionFlank, affected side up, table flexedSupineaxillary roll, pressure points padded, strapped
  3. Foley cathetersize
  4. Pre-incision cystoscopy / retrograde stent or ureteric catheterNot doneDone: details
  5. C-arm availableYesNo

Operative findings

  1. Stonenumber, size, surface, impacted or free
  2. Ureter / pelvisdilated above the stone, wall thickness, inflammation, periureteric fibrosis
  3. UrineClearTurbidPus (sent for culture)
  4. Distal and proximal patencyfeeding tube passed freely down and up, any more fragments
  5. Kidneysize, surface, perinephric adhesions

Procedure (steps)

  1. IncisionSubcostal flankSupracostal (11th / 12th rib)LumbotomyGibsonPfannenstiel / low midline (extraperitoneal)side, length
  2. Retroperitoneum entered, peritoneum swept mediallypleura intact or opened
  3. Ureter / pelvis identifiedperiureteric tissue kept; posterior segmental artery protected (pelvis)
  4. Stone localisedBulge seenPalpated
  5. Stone migration preventedvessel loops above and below the stone; feeding tube down the ureter for multiple pelvic stones
  6. Ureterotomy / pyelotomyLongitudinal ureterotomy over stoneU-shaped pyelotomy, apex 1 cm or more from PUJExtended into infundibulumSeparate radial nephrotomy for calyceal stoneblade used; length
  7. Stone removedintact or fragmented; instrument (Randall forceps / blunt dissector)
  8. Check for residual stonefeeding tube up and down; flexible scope / X-ray / C-arm
  9. DJ stentPlaced antegrade through the incisionRetrograde at startNot placed (reason)size and length; position checked
  10. Closure of ureter / pelvisinterrupted absorbable for ureter; running fine absorbable for pelvis; size
  11. CoverPeriureteric fatGerota's fascia closedNone

Closure, drains and dressing

  1. Draintype and size; placed near the ureterotomy but not touching it; separate stab
  2. Muscle layerslayers and suture; table flattened before tying
  3. SkinStaplesInterruptedSubcuticular
  4. Foley catheter left insize

Specimens and implants

  1. StoneSent for stone analysisGiven to patient
  2. Urine / stone for cultureSentNot sent
  3. DJ stentmake, size (Fr), length (cm), lot number; sticker pasted; planned 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. Vitals and urine outputcolour of urine; haematuria
  2. Drainoutput each shift; send drain fluid creatinine if output stays high
  3. Foley catheterremove on POD 1 or 2
  4. Drain removalabout 24 hours after catheter removal if output stays low
  5. Antibioticas per culture; drug, dose, duration
  6. Chestchest X-ray if the pleura was opened or breathing is difficult; incentive spirometry
  7. Analgesiaas on the drug chart
  8. Stent removalabout 4 weeks; give the patient a stent card with the date
  9. Follow-up imagingultrasound about 4 weeks after stent removal; MAG-3 scan if hydronephrosis
  10. Stone preventionstone analysis result; metabolic work-up for large stones

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. P.S., 38 years, with left flank pain for 3 months. CT KUB shows a 2.2 cm impacted stone in the left upper ureter at L3 with moderate hydronephrosis. Ureteroscopy with lithotripsy failed to reach the stone at another centre, and the patient chose open surgery.

Case details

Date: 11/07/2026. Elective left open ureterolithotomy. OT 2.

In OT 09:00. Induction 09:10. Skin incision 09:35. Closure completed 11:05.

Surgeon: Dr A. (2nd-year resident, Urology). Assistant: Dr B. Consultant: Dr C., scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: 2.2 cm impacted left upper ureteric stone after failed ureteroscopy.

X-ray KUB on 10/07/2026: stone still at L3. Creatinine 1.1 mg/dl. DMSA: left kidney 41% of total function.

Urine culture sterile. Blood grouped, 1 unit cross-matched.

Consent: general, procedure-specific and anaesthesia consent in Kannada. Explained urine leak, stricture, stent and its removal, pneumothorax.

Left side marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:12.

Anaesthesia and position

General anaesthesia. Foley 16 Fr passed. Right lateral position (left side up), 12th rib over kidney rest, table flexed, axillary roll, pressure points padded, strapped.

Parts painted with povidone-iodine and draped. C-arm available.

Procedure

Left subcostal flank incision of 12 cm, one finger breadth below the 12th rib. Latissimus dorsi, external and internal oblique divided with cautery. Subcostal nerve seen and kept.

Retroperitoneum entered at the tip of the 12th rib, peritoneum swept medially. Pleura not seen, not opened.

Ureter found on the psoas below the lower pole. Periureteric tissue kept on the ureter.

Findings: hard stone felt in the upper ureter at the level of the lower pole, 2.2 x 1 cm. Ureter above it dilated to about 1.5 cm. Some periureteric inflammation.

Vessel loops placed above and below the stone. Longitudinal ureterotomy of 2.5 cm made over the stone with a No. 15 blade.

Stone freed from the wall and removed intact. Clear urine came from above.

5 Fr feeding tube passed up to the pelvis and down to the bladder, both passed freely; saline flushed; no further fragment.

Guidewire passed through the ureterotomy into the bladder and then into the pelvis. 6 Fr, 26 cm DJ stent placed antegrade over the wire. Position checked on C-arm: upper coil in the pelvis, lower coil in the bladder.

Ureterotomy closed longitudinally with interrupted 4-0 polyglactin 910 (Vicryl), edges handled gently. Periureteric fat laid over the closure.

Closure

16 Fr tube drain placed near, not touching, the ureterotomy, brought out through a separate stab below the incision and fixed with silk 2-0.

Table flattened. Muscles closed in two layers with continuous No. 1 polyglactin 910 (Vicryl). Skin closed with staples.

Foley 16 Fr on free drainage, urine light pink.

Specimens and implants

Stone sent for chemical analysis.

Implant: DJ stent 6 Fr x 26 cm, make and lot number written on the implant sheet, sticker pasted in the file. Planned removal on or before 08/08/2026.

End of procedure

Estimated blood loss 100 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse. WHO sign out done.

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 84/min, BP 126/80 mmHg, SpO2 98% on room air.

Post-op orders

Pulse, BP, SpO2 and urine output 4-hourly.

Drain output charted each shift; send drain fluid creatinine if output stays high.

Foley removal on POD 1. Drain removal 24 hours later if output is low.

Incentive spirometry. Walk from POD 1.

Analgesia as on drug chart. Oral liquids after 6 hours.

Stent card given. DJ stent removal at 4 weeks. Ultrasound 4 weeks after stent removal. Review with stone analysis.

Signature

Dr A., JR-2, Urology. Reg. no. ________. 11/07/2026, 11:20.

Must document for this operation

  • Level of the stone, the incision used and why open surgery was chosen. Open stone surgery is now uncommon, so an auditor or another surgeon will look for the reason and the route.
  • The check that no fragments were left (feeding tube, scope or X-ray). A retained fragment explains persistent infection or obstruction later and changes follow-up.
  • DJ stent size, length, make and lot number, and planned removal date. The stent has to come out at a planned date, and NABH requires implant batch numbers in the record.
  • How the ureter or pelvis was closed and the suture used. If urine leaks or a stricture forms, the next surgeon needs this detail.
  • Whether the pleura was opened. The ward team needs to know whether to get a chest X-ray and watch for pneumothorax.
  • Drain position and when it should come out. The drain should lie near but not on the ureterotomy, and its removal is timed from catheter removal and output.

Common mistakes in these notes

  • Writing 'stone removed' without the stone size or the check for fragments.
  • No DJ stent details or removal date in the note or discharge summary.
  • Not re-confirming the stone position with imaging on the day, then not writing it.
  • Leaving out the suture used for the ureter.
  • Not stating whether the pleura was intact after a flank incision.

Indian practice and paperwork

  • The batch and serial number of an implanted device (here the DJ stent) must be recorded in the patient's record, the master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • NABH expects the operative note to be written before the patient is moved out of recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Consent must explain the procedure, risks, benefits, alternatives (ESWL, ureteroscopy, PCNL) and who will operate, in a language the patient understands. (NABH 5th ed., PRE.4(c))

Sources

  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 34, Ureterolithotomy (Krambeck AE, Blackburne A), pp. 307-310.
  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 22, Open stone surgery: anatrophic nephrolithotomy and pyelolithotomy (Ho L, Gutierrez-Aceves J), pp. 190-197.
  • Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Vol 3. Elsevier; 2026, Ch 141, Contemporary open surgery of the kidney: subcostal flank incision, pp. 2997.
  • 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. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf

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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Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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