Urology Operative Note (TURP/HoLEP)

Procedure Date: [Date]

Start Time / End Time: [Start time / End time]

Location: [Facility / OR number]

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s), credentials / N/A]

Anesthesia Type: [General / Spinal / Regional / MAC]

Pre-operative Diagnosis: [Diagnosis, e.g., benign prostatic hyperplasia with obstruction]

Post-operative Diagnosis: [Same as pre-op / Updated diagnosis]

Procedure(s) Performed: [Exact procedure name(s); for HoLEP specify "with morcellation" when applicable]

Wound Class: [Clean-contaminated / Other]

Antibiotic Prophylaxis: [Agent and dose] given at [timing relative to incision]

Estimated Blood Loss: [mL]

Pre-Procedure Verification

Informed consent was obtained after discussion of risks, benefits, and alternatives. [Heightened risk statement] (Only include if high-risk features present such as anticoagulation, very large gland, catheter dependence, or prior prostate surgery; state the specific elevated risk in one sentence.) Time-out was performed confirming correct patient, procedure, and site. The patient was positioned in lithotomy with all pressure points padded. Standard sterile prep and drape were performed.

Indications

[Narrative paragraph describing clinical indication(s) for surgery] (3–6 sentences. Include: primary indication such as LUTS refractory to medical therapy, urinary retention, recurrent UTI, hematuria from BPH, bladder stones, or renal insufficiency from obstruction; estimated prostate size if known; prior therapies; catheter dependence; anticoagulation status; relevant prior urologic procedures. If the choice of TURP vs HoLEP was explicitly made for a reason, briefly document why. Do not infer indications not stated in the encounter.)

Intraoperative Findings

• Meatus: [Caliber]; dilation [performed to size / not required]
• Urethra: [Normal / Stricture present at location with management]
• Prostate: [Configuration: bilobar / trilobar]; median lobe [present / absent]; [endoscopic size impression and obstruction severity]
• Landmarks: [Verumontanum, bladder neck, external sphincter region identified]
• Bladder: [Trabeculation, diverticula, stones, suspicious lesions, or unremarkable]
• Ureteral orifices: [Visualized bilaterally with appearance and location]
• Unexpected findings: [Findings / None]
• Enucleation plane: [Quality and complexity] (Include for HoLEP only if it affected case complexity.)

Procedure Description

Cystourethroscopy was performed. A [scope type] with [sheath size Fr] sheath was introduced under direct vision using [irrigation fluid type]. (Document irrigation fluid type especially for monopolar TURP.) A thorough bladder survey was performed, and the ureteral orifices were identified at [positions].

TURP

(Include only if TURP performed; omit entire section otherwise.)

A [monopolar / bipolar] resectoscope system was utilized with [electrosurgical system/model]. Cutting/coagulation settings were [cut setting / coag setting]. Resection was performed using a [resection strategy: median lobe first vs lateral lobes] approach with careful protection of the verumontanum and external sphincter. Resection depth was controlled to the level of capsular fibers. Hemostasis was obtained with [coagulation technique]. Prostatic chips were evacuated using [evacuation method/instrument]. The prostatic fossa and bladder neck were inspected; ureteral orifices were intact; [no perforation / perforation details and management]. [Concern for TUR syndrome: trigger and response] (Include only if concern arose.)

HoLEP

(Include only if HoLEP performed; omit entire section otherwise.)

A holmium:YAG laser was used with a [fiber size] fiber. Laser settings: enucleation [J, Hz / W / preset name]; hemostasis [J, Hz / W / preset name]. Enucleation was performed using a [2-lobe / 3-lobe / named] technique. The capsular plane was identified and maintained; apical release was performed with protection of the external sphincter. Enucleated lobes were pushed into the bladder. The prostatic fossa was inspected and hemostasis achieved prior to morcellation.

Morcellation

(Include only if morcellation performed; omit entire section otherwise.)

Morcellation was performed using [morcellator device] under continuous visualization with [bladder distension/irrigation strategy]. [Morcellation difficulty and mitigation] (Include only if applicable.) Post-morcellation cystoscopic inspection of bladder mucosa and ureteral orifices was performed; [findings including explicit statement regarding bladder injury: present / absent].

Completion: The prostatic fossa and bladder were reinspected. Hemostasis was [satisfactory / additional measures taken]. The patient tolerated the procedure without apparent immediate complications.

Specimens

• Primary specimen: [Prostate chips (TURP) / Morcellated prostate tissue (HoLEP)] labeled as [label], sent to pathology
• Tissue weight: [g / weight pending pathology]
• Additional specimens: [Bladder stones, biopsies, cultures with labels and destinations / None]

Catheter and Irrigation

• Catheter: [2-way / 3-way] Foley, [size Fr], balloon inflated to [mL]; traction [applied with method / not applied]
• Initial urine return: [Clear / light pink / bloody]; clots [present / absent]
• Continuous bladder irrigation: [Started with target effluent color and stop criteria / Not initiated]
• Manual irrigation: [Instructions / N/A]

Complications

[Complication(s) with management: capsular perforation, significant bleeding, bladder injury, ureteral orifice injury, TUR syndrome, urethral false passage, morcellation difficulty, conversion, or aborted case] (If none: "No intraoperative complications apparent.") [For HoLEP with morcellation, state: Bladder injury on post-morcellation inspection: present / absent]

Disposition

Destination: [PACU / Floor / ICU]

Condition: [Stable / Hemodynamically stable / Specify abnormalities]

Postoperative Plan

• CBI: [Titration instructions and stop criteria / N/A]
• Catheter: [Anticipated duration / void trial timing]
• Clot retention: [Manual irrigation protocol and escalation criteria]
• Labs: [H/H, electrolytes, other / None indicated]
• Antibiotics: [Perioperative only / Short course with agent and duration]
• Anticoagulation/antiplatelet: [Restart timing and criteria / N/A]
• Activity: [Restrictions and duration]
• Pathology: [Who reviews and communicates results; timeline]
• Follow-up: [Timeframe] to assess [voiding symptoms, hematuria resolution, continence]