Urology Operative Note (Ureteroscopy with Laser Lithotripsy +/- Stent)

Patient: [Patient name]   MRN: [Medical record number]   DOB: [Date of birth]   Date of Procedure: [Procedure date]   Procedure Start Time: [Start time]   Procedure End Time: [End time]   Facility/Location: [Facility or location]   Surgeon: [Primary surgeon]   Assistant(s): [Assistant(s)] (Only include if applicable)   Anesthesia Type: [general / MAC / regional / local]   Procedure Urgency: [elective / urgent / emergent]

Preoperative Diagnosis

[Stone diagnosis with laterality and anatomic location] (Laterality is required. Include associated conditions only if they influenced intraoperative decisions, such as hydronephrosis, solitary kidney, prior stent/nephrostomy, or anticoagulation considerations.)

Indication for Procedure

[Clinical rationale for ureteroscopy with laser lithotripsy] (Note relevant context such as failure of medical expulsive therapy, symptomatic obstruction, need for staged procedure after decompression, or patient preference.)

Preoperative Urine Status and Antibiotics

• Urinalysis: [Key findings and collection date] (Include pyuria, nitrites, leukocyte esterase, or other relevant findings.)
• Urine culture: [negative / positive with organism / contaminated / pending / unknown at time of procedure] — [Collection date] (If unknown or pending, document actions taken such as prophylaxis given and intraoperative culture sent.)
• Infection risk modifiers: [Indwelling stent / nephrostomy / recurrent UTIs / fever / immunosuppression / none] (Include only if applicable.)
• Perioperative antibiotics: [Agent, dose, and timing relative to procedure start] (If on therapeutic antibiotics for known infection, document agent and whether urine was sterilized prior to intervention.)

Postoperative Diagnosis

[Postoperative stone diagnosis with laterality and anatomic location] (If findings differed from preoperative expectations—such as stone migration, no stone found, or additional stones—explicitly note changes.)

Procedure(s) Performed

• [Cystoscopy]
• [Left / Right / Bilateral] ureteroscopy [semirigid / flexible / semirigid and flexible]
• [Holmium / Thulium] laser lithotripsy of [Left / Right] [anatomic location] stone
• [Left / Right] ureteral stent placement, [diameter] Fr × [length] cm (Only if performed)
• [Left / Right] retrograde pyelogram (Only if performed)

[Planned procedure(s) not performed and reason] (Document any planned steps that were omitted with rationale; omit this line if all planned procedures were performed.)

Intraoperative Findings

• [Ureteral orifice appearance with laterality]
• [Ureteral caliber, edema, strictures, or narrowing with location and laterality] (Include only if abnormal.)
• [Stone characteristics: laterality, location, size in mm, number, degree of impaction]
• [Collecting system appearance] (Include only if visualized.)
• [Urine appearance: clear / turbid / purulent] (If purulent urine encountered, state whether stone treatment was aborted or continued, cultures obtained, and how drainage was established.)

Procedure Description

[Ureteral access details] (Include cystoscope used; guidewire type/size; whether safety wire maintained; ureteral dilation method and size if performed; ureteral access sheath size if used.)

[Ureteroscopy details] (Specify semirigid and/or flexible scope; retrograde pyelogram if performed; irrigation method if clinically relevant.)

[Laser lithotripsy details] (State laser type—holmium:YAG or thulium fiber; fiber size; treatment strategy—dusting vs fragmentation; representative settings—energy in Joules and frequency in Hz. Describe technique such as relocating stone to renal pelvis or stabilizing ureteral stone.)

[Lithotripsy result and fragment management] (Document residual fragment status with size estimates. If basket extraction performed, note basket type and that fragments were retrieved for analysis. If no basket used, state rationale.)

[Ureteral evaluation on withdrawal] (If no injury identified, state: "No visible ureteral injury on withdrawal inspection." If injury occurred, specify type—mucosal abrasion vs perforation—location, and management.)

[Stent placement decision] (If placed: state indication, laterality, diameter in Fr, length in cm, whether string left attached, and confirmation of coil positioning. If not placed: state "No ureteral stent placed" with rationale.)

[Procedure completion] (Note Foley catheter placement if applicable; confirm adequate hemostasis.)

Specimens

• [Stone fragments for composition analysis with laterality] (Include only if obtained.)
• [Intraoperative urine culture with source] (Include only if obtained.)

(If no specimens obtained, state "None.")

Implants

[Left / Right] ureteral stent: [diameter] Fr × [length] cm, [manufacturer if known], string [left in place / not left in place] (Include only if stent placed; otherwise omit entire section.)

Estimated Blood Loss

[Numeric estimate in mL] or Minimal

Complications

[Complication description, timing, and management] or None (If complication occurred, specify timing—during access, lithotripsy, or withdrawal—and management taken.)

Disposition

[stable / guarded]; to [PACU / floor / ICU]; [admit / discharge]

Postoperative Plan

• Stent plan: [Removal timeframe or date]; [office cystoscopy / string self-removal / planned second-look]; [patient instructions if string present] (Include only if stent placed.)
• Antibiotics: [Prophylaxis only / Therapeutic course with agent, duration, and rationale] (If infection encountered, document culture-directed therapy plan.)
• Pain management: [Analgesia strategy] (Include alpha-blocker or antispasmodic for stent symptoms if prescribed.)
• Follow-up: [Clinic follow-up timeframe]; [Imaging plan: ultrasound / KUB / CT with timing]; [Stone analysis review and metabolic evaluation plan]

Surgeon Signature

[Electronic signature], [Date and time]

(Generation meta-instructions: Laterality must be documented for every diagnosis, procedure, and implant. If preoperative urine culture status is unknown, state "unknown at time of procedure" and document actions taken. For stent decisions, always document either stent details with removal plan OR explicitly state no stent placed with rationale. Do not autopopulate negative findings unless they reflect actual assessment. If information is not provided, omit the field rather than using placeholder text, except for complications which should state "None" if uncomplicated.)