Urology Operative Note (TURBT/Fulguration)

Date of Procedure: [Date]

Surgeon: [Primary surgeon; include assistants and roles if present]

Anesthesia: [general / regional / MAC / local]

Procedure(s) Performed: [Procedure name(s)] (Use explicit terminology such as "Cystoscopy with transurethral resection of bladder tumor and fulguration" or "Cystoscopy with fulguration of bladder tumor(s), no resection." List adjunct procedures separately if performed.)

Preoperative Diagnosis: [Preoperative diagnosis]

Postoperative Diagnosis: [Postoperative diagnosis]

Indications

[Indication for procedure] (Include brief statement such as hematuria workup finding, surveillance recurrence, or positive cytology. Note relevant prior bladder cancer history if it affects current management, including prior grade/stage and intravesical therapy. Do not infer stage/grade if not explicitly known.)

Informed consent was obtained and time-out was performed.

Exam Under Anesthesia

Bimanual examination [performed before resection / performed after resection / performed before and after resection / not performed]. Findings: [mobile / fixed], [palpable mass present / no palpable abnormality]. (If not performed, omit findings.)

Cystoscopic Findings

Complete inspection of the urethra and bladder was performed, including the bladder neck and bilateral ureteral orifices. [General bladder and urethral findings] (Note presence or absence of flat erythematous or velvety areas suspicious for CIS, diverticula, ureteral orifice involvement, stones, trabeculation, or other relevant findings.)

Tumor Inventory:

• Tumor 1: Location: [bladder region] at [clock-face position], [relationship to ureteral orifices if relevant]; Size: [cm] [measured / estimated]; Appearance: [papillary / sessile / flat], [pedunculated / broad-based]; Endoscopic impression: [non-invasive appearing / suspicious for invasion]
• (Repeat for each additional tumor. If accurate count not feasible, state "multiple/innumerable" with overall description.)

Summary: [Brief global summary of tumor burden and distribution] (Do not infer grade or stage.)

Procedure Details

The patient was positioned in lithotomy and prepped and draped in the usual sterile fashion. A [cystoscope type] was inserted per urethra to the bladder. A [resectoscope type/size] was utilized. Energy modality: [monopolar / bipolar]. Fulguration method: [loop / Bugbee electrode / roller ball / laser].

Resection approach: [en-bloc / piecemeal-fractionated]. (If fractionated, specify whether separate specimens were collected for exophytic portion and tumor base/deep component.)

Detrusor sampling intent: [Deep resection performed with intent to sample muscularis propria / Deep sampling limited or not performed due to: thin bladder wall / proximity to ureteral orifice / perforation risk / obturator reflex / anticoagulation / other reason]. (If not documented, insert [Not documented].)

Completeness of tumor treatment: [Visually complete resection achieved / Incomplete - residual tumor at location due to reason, plan for staged resection or re-TURBT]. (If not documented, insert [Not documented].)

Hemostasis: [Adequate hemostasis achieved / Hemostasis requiring additional intervention - describe].

Perforation assessment: [No evidence of perforation / Suspected perforation - findings and actions / Confirmed perforation - findings and actions]. (If not documented, insert [Not documented].)

Adjunct procedures: [Random biopsies / mapping biopsies / prostatic urethral biopsy / retrograde pyelogram / ureteral stent placement / bladder wash cytology / none]. (Briefly describe sites and technique if performed.)

Specimens

• Container A: [Tumor number, site/location, exophytic portion / base-deep specimen / biopsy site]
• Container B: [Tumor number, site/location, exophytic portion / base-deep specimen / biopsy site]
• (Add additional containers as needed.)

(For fulguration-only cases: "No specimens obtained; fulguration only." Include clinical justification such as known low-grade Ta history with small recurrent papillary lesions.)

Intravesical Therapy

Immediate instillation: [Given / Not given]

If given: [Agent and dose], administered [in OR / in PACU], dwell time [duration] with [drainage plan].

If not given, reason: [Not indicated / concern for perforation or thin bladder wall / extensive resection with extravasation risk / significant bleeding requiring CBI / tumor appeared invasive / allergy or contraindication / logistical reason].

(This section is required. If not addressed in dictation, insert [Not documented].)

Complications

[No intraoperative complications / Complication occurred: description] (Document obturator reflex with consequence, bleeding requiring intervention, perforation, ureteral orifice injury, or other complications. If not documented, insert [Not documented].)

Catheter and Disposition

Foley Catheter: [Size] Fr [2-way / 3-way]; continuous bladder irrigation [not used / initiated with effluent character]

Estimated Blood Loss: [mL / minimal]

Disposition: [Patient condition and destination]

Follow-up Plan

Specimens sent to pathology. Results will be reviewed with the patient [timeframe and method if known].

[Conditional next steps] (If high-grade or T1 pathology returns or detrusor sampling is inadequate, note whether re-TURBT will be considered and approximate timeframe. For fulguration-only cases, document surveillance plan and triggers for future biopsy or resection.)