OT notes · Urology

Ureteroscopic lithotripsy (URSL) with DJ stenting

Usual anaesthesia
Spinal or general
Position
Dorsal lithotomy on a radiolucent table
Setting
elective

Operative note template for ureteroscopic lithotripsy with double-J stent placement, with a filled example for semirigid laser lithotripsy of a lower ureteric stone under spinal anaesthesia.

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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

  • infection and urosepsis
  • blood in urine and flank pain
  • ureteric perforation, and rarely avulsion of the ureter
  • ureteric stricture later (under 1%)
  • stone moving up into the kidney, or residual fragments needing another procedure
  • procedure stopped with only a stent placed if the ureter is too tight, and a second procedure after 1 week or more
  • stent symptoms: frequency, urgency, burning, flank pain, blood in urine
  • stent must be removed on time; a forgotten stent can block, encrust and damage the kidney

Pre-operative details for this operation

  1. Stone details on imagingside, site (upper / mid / lower ureter, relation to iliac vessels), size in mm, number, density if CT; hydronephrosis grade
  2. Imaging daterecent imaging confirms the stone is still there
  3. Urine culturesterile / organism treated; any fever or sepsis this episode
  4. Renal functioncreatinine; solitary kidney?
  5. Pre-stented or nephrostomyNoDJ stent in situ since dateNephrostomy in situ since date
  6. Anticoagulants / antiplateletsdrug and date stopped

Anaesthesia and position

  1. AnaesthesiaSpinalGeneral (endotracheal)General (LMA)LMA can cause breathing movement that disturbs the view
  2. PositionDorsal lithotomySupineLateral
  3. FluoroscopyC-arm or fluoroscopy table; screening time
  4. Irrigationnormal saline; gravity / hand pump / automated; total volume

Operative findings

  1. Bladder and ureteric orificenormal / oedematous; efflux
  2. Retrograde pyelogramlevel of filling defect, degree of dilatation above, anatomy
  3. Stonesite, size, colour, hard / soft, impacted or free
  4. Ureteric mucosa at stone siteNormalOedematousPolypsNarrowing
  5. Pus above stoneNoYes (culture sent, procedure stopped, stent placed)

Procedure (steps)

  1. Cystoscopy and ureteric orifice identified
  2. Retrograde pyelogram5 Fr open-ended catheter, contrast
  3. Safety guidewire placed to kidneywire type; position confirmed on fluoroscopy
  4. Ureteric accessScope passed alongside safety wireSecond wire (train-tracking)Balloon / serial dilatation (size)Access sheath (size, length)
  5. UreteroscopeSemirigidFlexiblesize in Fr
  6. LithotripsyHolmium:YAG laserThulium fibre laserPneumaticElectrohydraulicfibre size; energy (J), frequency (Hz), power (W; keep to 10 W or less in the ureter)
  7. FragmentationDustedFragmented and basketedPart migrated to kidney
  8. Fragment retrievalbasket type; under direct vision; one piece kept for stone analysis
  9. Final ureteroscopyureter free of fragments, no injury; any perforation graded
  10. Completion retrograde pyelogramNo extravasationExtravasation (site)
  11. Stone clearanceCompleteResidual fragments (size, site)

Closure, drains and dressing

  1. DJ stentside, diameter (Fr), length (cm), make; tether left or cut; curls confirmed in kidney and bladder on fluoroscopy / cystoscopy
  2. Reason for stent (or for stentless)PerforationDilatation over 10 FrOedema / impacted stoneInfectionMany fragments to passSolitary kidneyRoutine (surgeon preference)
  3. Planned stent removal dateexact date; entered in stent register; patient told in writing
  4. Urethral cathetersize (Fr), balloon volume, planned removal

Specimens and implants

  1. Stone fragment for chemical analysisSentNot retrieved
  2. DJ stentmake, size, lot/batch; sticker pasted
  3. Other consumablesguidewire, basket, access sheath, laser fibre if single use: make and lot
  4. Urine / pus cultureif sent

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 temperaturefever or chills may mean urosepsis: inform at once, send blood and urine culture
  2. Urine colourmild haematuria expected
  3. Urethral catheterremoval time
  4. AnalgesiaNSAID if renal function allows; drug, dose, frequency
  5. Stent symptom reliefalpha-blocker and / or anticholinergic if troublesome
  6. Antibioticsonly if infected system or sepsis this episode: drug, dose, duration
  7. Stent removalexact date written on discharge summary and in stent register
  8. Follow-up imagingKUB / ultrasound / CT as planned, for residual stone or hydronephrosis
  9. Stone analysis reportreview at follow-up

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. R.M., 38 years, height 168 cm, with a 9 mm left lower ureteric stone below the iliac vessels and moderate hydroureteronephrosis, not passed after 4 weeks of medical expulsive therapy.

Case details

Date: 02/09/2026. Elective. OT 6.

In OT 09:00. Spinal given 09:10. Scope in 09:25. End 10:05.

Surgeon: Dr A. (2nd-year resident, MCh Urology). Assistant: Dr B. Consultant: Dr C., present in OT.

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

Indication and pre-op

NCCT KUB 28/08/2026: 9 x 6 mm calculus in left lower ureter, 3 cm above the vesicoureteric junction, moderate left hydroureteronephrosis. Right kidney normal.

Urine culture sterile. No fever this episode. Creatinine 1.1 mg/dl. Not on anticoagulants.

Consent: general, procedure-specific (including stent, stent symptoms, need for stent removal, possible second procedure) and anaesthesia consent taken in Marathi; wife as witness.

WHO checklist sign in and time out done. Left side marked. Inj cefazolin 2 g IV at 09:05, single pre-op dose.

Anaesthesia and position

Spinal anaesthesia. Dorsal lithotomy on radiolucent table, pressure points padded. C-arm on the right side.

Parts painted with povidone-iodine and draped. Normal saline irrigation by gravity and hand pump.

Findings

Bladder normal. Left ureteric orifice normal, no efflux.

Retrograde pyelogram: filling defect in the left pelvic ureter below the iliac vessels with dilated ureter and pelvicalyceal system above.

Yellow-brown hard stone about 9 mm, partly impacted, with mild mucosal oedema at the stone site. No pus.

Procedure

Rigid cystoscopy. 5 Fr open-ended catheter placed at the left orifice and retrograde pyelogram done.

PTFE-coated safety guidewire passed through the catheter to the left renal pelvis, position confirmed on fluoroscopy. Bladder drained.

Semirigid ureteroscope (8/9.8 Fr) passed alongside the safety wire into the left ureter without dilatation. Stone seen.

Holmium:YAG laser lithotripsy with 365 micron fibre, starting 0.6 J x 6 Hz (3.6 W), increased to 0.8 J x 8 Hz (6.4 W). Stone fragmented to small pieces with little movement upwards.

Fragments removed one at a time with a nitinol basket under direct vision. One fragment kept for stone analysis. Small dust left to flush.

Ureter inspected up to the pelvic brim: no significant fragments left, mucosa intact, no perforation.

Completion retrograde pyelogram: no extravasation, contrast drains freely.

Irrigation used about 1.5 litres. Fluoroscopy time 45 seconds.

Closure

Left DJ stent 6 Fr x 22 cm placed over the safety wire under fluoroscopy and cystoscopic vision. Upper curl in renal pelvis and lower curl in bladder confirmed. Tether removed.

Reason for stent: impacted stone with mucosal oedema.

14 Fr Foley catheter, balloon 10 ml, bladder drained.

Planned stent removal: 23/09/2026 (3 weeks), by cystoscopy. Entered in OT stent register. Date written on the discharge summary and explained to patient and wife.

Specimens and implants

Stone fragment sent for chemical analysis.

DJ stent: make ______, 6 Fr x 22 cm, lot ______. Sticker pasted in file and entered in OT implant register. Basket make ______, lot ______.

End of procedure

Blood loss nil measurable. No transfusion.

Instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 78/min, BP 124/78 mmHg, temperature 98.4 F.

Post-op orders

Pulse, BP and temperature 4-hourly. Inform if temperature rises or chills.

Foley catheter out tomorrow morning.

NSAID analgesic if creatinine normal (drug, dose in drug chart).

Tab tamsulosin once daily till stent removal, for stent discomfort.

Oral fluids when awake, then normal diet. Drink plenty of water.

X-ray KUB before discharge to confirm stent position.

Stent removal on 23/09/2026. Review stone analysis report then.

Signature

Dr A., SR, Urology. Reg. no. ________. 02/09/2026, 10:20.

Must document for this operation

  • Stent side, diameter, length, and whether a tether was left. The next urologist needs this to remove or exchange the stent, and a tethered stent can be pulled out by accident.
  • The exact date the stent must be removed, entered in the stent register and on the discharge summary. Forgotten stents can encrust and block, may need several operations to remove and can cost the kidney.
  • Stone site, size and how much was cleared, with any residual fragments. It decides follow-up imaging and whether another procedure is needed.
  • Safety wire used and completion retrograde pyelogram result. This is the record that the ureter was protected and found intact at the end.
  • Any ureteric injury or perforation and its extent. It changes stent dwell time and explains a later stricture.
  • Laser settings and fluoroscopy time. They are needed for audit of thermal and radiation safety.
  • Reason for placing a stent. Stents cause symptoms, so the note should show why one was needed.

Common mistakes in these notes

  • Writing 'DJ stent placed' with no size, length or removal date.
  • No entry in the stent register, so the patient is lost to follow-up.
  • No mention of a safety wire.
  • Not recording residual fragments or stone migration to the kidney.
  • Stone fragment not sent for analysis.
  • Laser settings or fluoroscopy time left out.

Indian practice and paperwork

  • A DJ stent is an implanted device: NABH requires its batch and serial number to be recorded in the patient's record, the master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • NABH expects post-operative care to be guided by a documented plan; for a stented patient that plan must include the removal date. (NABH 5th ed., COP.14(f))
  • A properly written operative note protects the surgeon if negligence is alleged after an operative complication; an unsigned record has no legal validity. (Thomas J. Indian J Urol 2009;25(3):384-8, PMID 19881136)

Sources

  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, et al., eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 36, Ureteroscopic instrumentation (Forbes CM et al.); Ch 37A, Ureteroscopic management of ureteral calculi (Medairos RA et al.), pp. 315-326.
  • Smith AD, Preminger GM, Kavoussi LR, Badlani GH, eds. Smith's Textbook of Endourology. 4th ed. Wiley; 2019, Ch 55, Ureterorenoscopy: ureteral stents and postoperative care, pp. 642-652.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; prophylaxis under 24 hours for most procedures. academic.oup.com/ajhp/article/70/3/195/5112717
  • Hinman 5e Ch 36-37A, printed pp. 315-325: at least one pre-op antibiotic dose per local antibiogram; safety wire mandatory; irrigation under 200 cmH2O; Ho:YAG hard stone start 0.6 J x 6 Hz; 10 W or less in the ureter; stent dwell 48 h to 4 weeks for uncomplicated URS; re-attempt after at least 1 week of stenting.

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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