OT notes · Urology

Urethroplasty (anastomotic / buccal mucosa graft)

Usual anaesthesia
General with endotracheal intubation (needed if buccal mucosa is harvested)
Position
Lithotomy (low or modified), buttocks at the edge of the table
Setting
elective

Operative note template for anterior (bulbar) and posterior urethroplasty, anastomotic or with buccal mucosa graft, with a filled example for a dorsal onlay buccal mucosa graft urethroplasty for a 4 cm bulbar stricture.

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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

  • recurrence of stricture needing further dilatation, urethrotomy or surgery
  • erectile dysfunction
  • ejaculatory problems and post-void dribbling
  • penile shortening or curvature (chordee)
  • urine leak or fistula from the repair
  • perineal and scrotal numbness, bruising and haematoma
  • mouth pain, numbness or tightness at the buccal graft site
  • nerve injury, compartment syndrome or DVT from the lithotomy position
  • incontinence (mainly after posterior urethroplasty)

Pre-operative details for this operation

  1. Stricture site and lengthfrom retrograde urethrogram (RGU) with or without voiding cystourethrogram (VCUG) or urethral ultrasound: meatus / penile / bulbar / membranous, length in cm
  2. CauseIdiopathicStraddle / perineal traumaPelvic fracture urethral injuryIatrogenic (catheter, TURP)Lichen sclerosusInfective
  3. Previous treatmentnumber of dilatations, internal urethrotomies, previous urethroplasty
  4. Suprapubic catheter in situNoYes: since (date), size
  5. Urine cultureresult and treatment before surgery
  6. Baseline flow and symptomsQmax, post-void residual, symptom and erection scores if used
  7. Oral cavity checked for grafttobacco use, lichen planus, previous oral radiotherapy, mouth opening
  8. Hip mobility for lithotomy

Anaesthesia and position

  1. AnaesthesiaGeneral with endotracheal tubeSpinal (only if no oral graft)
  2. PositionLow / modified lithotomyExaggerated lithotomystirrups used, padding over fibular head, who checked the position
  3. Intermittent pneumatic compression on both legsYesNo
  4. Time in lithotomylegs brought down periodically in long cases

Operative findings

  1. Urethral calibrationbougie-a-boule size passed, other strictures in meatus / penile urethra
  2. Stricture length and location at surgerymeasured length after urethrotomy, compared with the RGU
  3. Urethral plate width at narrowest pointin mm (5 mm or more can be augmented)
  4. SpongiofibrosisPartial thicknessFull thickness
  5. Posterior urethra (PFUDD)gap length, level of the proximal end, bladder neck on cystoscopy
  6. False passages, stones or fistula

Procedure (steps)

  1. Calibration and wirebougie-a-boule / cystoscopy; guidewire and 5 Fr ureteric catheter across stricture
  2. Perineal incisionMidline perineallength
  3. BulbospongiosusDivided in midlineRetracted caudally
  4. Urethral mobilisationOne-sided (dorsal approach)Circumferentialextent (from penoscrotal junction to bulbomembranous junction)
  5. Type of repairExcision and primary anastomosis (EPA)Nontransecting anastomoticDorsal onlay BMGVentral onlay BMGAugmented anastomotic (EPA + BMG)Staged (first stage)Posterior anastomotic (PFUDD)
  6. Urethrotomy / excisiondorsal or ventral; extended until what size bougie passes distally and proximally; length excised
  7. Spatulation (anastomotic)which end spatulated which way, length in cm; tension checked with penis on stretch
  8. Buccal mucosa harvestside, size (length x width in cm), Stensen duct preserved, local infiltration, donor site closed or left open, haemostasis
  9. Graft preparation and fixationfat removed, quilting to corpora / spongiosum, suture size and material
  10. Anastomosis / graft edgesnumber of sutures, material and size, interrupted or running, layers
  11. Posterior urethroplasty manoeuvres (PFUDD)Bulbar mobilisation onlyCrural separationInferior pubectomySupracrural rerouting
  12. Urethral cathetertype and size (Fr), balloon volume
  13. Suprapubic catheterNot placedRetainedNew SPC placed

Closure, drains and dressing

  1. Spongiosum / bulbospongiosussuture and layers
  2. Colles fascia and subcutaneous tissuesuture
  3. Skinsuture
  4. Local anaesthetic infiltrationdrug, strength, volume
  5. DrainNonePerineal drain
  6. Dressing and scrotal support
  7. Catheter fixed to thigh without tension

Specimens and implants

  1. Excised stricture segment for HPESentNot applicable (nontransecting / graft only)especially if lichen sclerosus or malignancy is suspected
  2. Catheters lefturethral and suprapubic: type, size, lot number

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. Catheter careurethral catheter fixed to thigh without tension, closed drainage
  2. Legscheck sensation, movement and calf pain after lithotomy (nerve injury, compartment syndrome, DVT)
  3. Mouth care (if BMG)mouthwash, soft diet as tolerated
  4. Scrotum and perineumscrotal support and elevation for swelling
  5. Analgesiadrug, dose, frequency
  6. Antibioticperioperative prophylaxis stopped within 24 hours; one dose before catheter removal or contrast study
  7. Catheter removal planEPA: 1 to 2 weeks, no routine imaging; BMG or complex repair: VCUG or pericatheter RGU at 2 to 3 weeks first
  8. Activityno heavy lifting while catheter in; no sexual activity for 4 to 6 weeks; no cycling for 3 months
  9. Follow-up3 to 6 months: uroflowmetry, post-void residual, cystoscopy

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. V.D., 38 years, idiopathic bulbar urethral stricture, 4 cm long on retrograde urethrogram, after two previous internal urethrotomies. Qmax 6 ml/s. Urine culture sterile.

Case details

Date: 18/06/2026. Elective. OT 4.

In OT 09:00. Induction 09:10. Incision 09:35. End 12:20.

Surgeon: Dr A. (consultant, Urology). Assistant: Dr B. (MCh resident, did the buccal harvest under supervision). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: recurrent 4 cm mid-bulbar stricture after two optical internal urethrotomies. No SPC.

Oral cavity normal, non-smoker, no tobacco chewing. Hip movements normal.

Consent: general, procedure-specific (recurrence, erectile and ejaculatory change, chordee, fistula, mouth pain, lithotomy risks) and anaesthesia consent taken in Hindi.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:15, before incision.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Low lithotomy in padded stirrups, buttocks at edge of table; position checked by Dr A. Intermittent pneumatic compression on both legs.

Perineum painted with povidone-iodine and draped.

Procedure

Calibration: meatus and penile urethra take 22 Fr bougie-a-boule. Hold-up at bulbar urethra. Guidewire passed across the stricture on cystoscopy and railroaded with a 5 Fr ureteric catheter.

Midline perineal incision about 6 cm. Colles fascia divided. Bulbospongiosus divided in the midline.

Bulbar urethra mobilised off the corpora on the left side only, keeping the right lateral attachments.

Dorsal urethrotomy with No. 15 blade over the ureteric catheter. Holding sutures polyglactin 910 (Vicryl) 4-0. Urethrotomy extended distally till 28 Fr and proximally till 30 Fr bougie-a-boule passed. Length of urethrotomy 4.5 cm. Ventral urethral plate 8 mm wide at the narrowest point. Partial-thickness spongiofibrosis.

Buccal mucosa harvest (Dr B.): left cheek, graft 5 x 2 cm marked away from Stensen duct, infiltrated with bupivacaine with adrenaline, dissected off buccinator. Bleeding points cauterised, adrenaline-soaked gauze packed. Donor site not closed.

Fat removed from the graft on the back table. Graft quilted to the corpora cavernosa in three rows with poliglecaprone (Monocryl) 5-0.

Proximal and distal apices sutured with interrupted Monocryl 5-0, sides of the urethral plate to the graft edges with running Monocryl 5-0.

16 Fr silicone Foley catheter passed, balloon 10 ml.

Closure

Bulbospongiosus, subcutaneous fat, Colles fascia and skin closed with 4-0 absorbable sutures, wound irrigated with saline between layers.

0.25% bupivacaine 15 ml infiltrated into the incision. No drain.

Dressing and scrotal support. Catheter fixed to the thigh without tension. Mouth gauze removed, cheek dry.

End of procedure

Estimated blood loss 100 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications. Time in lithotomy recorded from positioning to taking the legs down; legs brought down to supine on the stirrups for 10 min at 2 hours. Legs checked at the end, pulses present.

Specimen: none (nontransecting repair).

Extubated, shifted to recovery. Pulse 80/min, BP 124/76 mmHg.

Post-op orders

Vitals 4-hourly. Check both legs for sensation, movement and calf pain.

Oral liquids after 4 hours, soft diet next day. Chlorhexidine mouthwash after meals.

Analgesia as per drug chart. No further antibiotic after 24 hours.

Catheter to closed drainage, fixed to thigh. Scrotal support.

VCUG at 3 weeks. Catheter out if no leak; one antibiotic dose before the study.

No sexual activity for 6 weeks, no cycling for 3 months. Review at 3 months with uroflowmetry and post-void residual.

Signature

Dr B., MCh resident, Urology, for Dr A. Reg. no. ________. 18/06/2026, 12:40.

Must document for this operation

  • Stricture length and site measured at surgery, and the width of the urethral plate. These decide the type of repair and are compared with the urethrogram in any audit of recurrence.
  • The exact repair: EPA, nontransecting, dorsal or ventral onlay, augmented, staged or posterior. The next surgeon plans any redo repair from this, and outcomes differ by technique.
  • Graft donor site, size and whether Stensen duct was seen and preserved. If more graft is needed later, the other cheek or tongue is used, and parotid duct injury is a known complaint.
  • Bougie sizes reached distally and proximally, and catheter size left. These show the calibre achieved and guide later calibration or catheter changes.
  • Lithotomy position, padding and total time in stirrups. Nerve injury and compartment syndrome after long lithotomy cases are medicolegal issues, and the note must show care was taken.
  • Written plan for catheter removal and contrast study. Early removal before a leak is ruled out after graft repair can cause fistula or failure.

Common mistakes in these notes

  • Writing 'urethroplasty done' without naming the technique or the side of the graft.
  • Copying the stricture length from the urethrogram instead of measuring it at surgery.
  • Not recording the buccal graft size and donor side.
  • Leaving out the time in lithotomy and who checked the leg position.
  • No plan for when the catheter comes out and whether a voiding cystourethrogram (VCUG) is needed first.
  • Not recording whether an existing suprapubic catheter was kept or removed.

Indian practice and paperwork

  • 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))
  • Name every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist though two had given anaesthesia. (Thomas J. Indian J Urol 2009;25(3):384-8, PMID 19881136)
  • If a stricture segment is excised and not sent for HPE, it is human anatomical waste for the yellow bag. Formalin discarded from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Smith JA Jr, Howards SS, Preminger GM, Dmochowski RR, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 89, Reconstruction of Strictures of the Bulbar Urethra (Vanni AJ), pp. 730-739.
  • Smith JA Jr, Howards SS, Preminger GM, Dmochowski RR, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 90, Reconstruction of Pelvic Fracture Urethral Injuries (Chapple CR), pp. 740-754.
  • Keane TE, Graham SD Jr, eds. Glenn's Urologic Surgery. 8th ed. Wolters Kluwer; 2016, Ch 39, Anterior Urethral Stricture Disease (Wessells H): decision making, positioning, antibiotics, buccal mucosal harvest, post-op care, e-book PDF pp. 578-584, 591.
  • 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; duration under 24 hours. 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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