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Genitourinary Specialist
30-45 minutes

Operating Room: Ureteroscopy with Laser Lithotripsy Template

The s10.ai ureteroscopy and laser lithotripsy operative report template is expertly crafted for urologists, especially those with a focus on endourology. This template offers a detailed framework for accurately documenting the surgical removal of kidney stones using a ureteroscope and laser lithotripsy. It encompasses sections for preoperative and postoperative diagnoses, meticulous procedural steps, laser settings, and any complications that may arise. By ensuring comprehensive documentation of the surgical process, this template is essential for maintaining accurate patient records and facilitating effective follow-up care. Urologists looking to adopt a standardized method for documenting ureteroscopic procedures will find this template invaluable.

4,589 uses
4.9/5.0
M
Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

"DATE OF OPERATION: [today's date in US format]
PATIENT: [Patient's name]
DOB: [Patient's date of birth in US format]
MEDICAL RECORD NUMBER: [Patient's medical record number]
SURGEON:
s10.ai
ASSISTANTS:
[Name of residents participating in the case, if not mentioned put "None."]
PREOPERATIVE DIAGNOSIS:
Urolithiasis (if more details about stone size and location please put that here instead)
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE:
1. Cystoscopy
2. Ureteroscopy and laser lithotripsy (please put laterality when mentioned).
(if stone size/location provided, add: "Stone size: [stone size] mm, Location: [stone location]")
(if rigid or flexible scope used, edit: "[Rigid/Flexible] ureteroscopy")
3. Retrograde pyelogram (if mentioned, otherwise omit this procedure)
KEY DETAILS:
(if flexible and sheath used, add: "Ureteral access sheath used")
(if nephroscopy findings, add: "Nephroscopy findings: [nephroscopy findings]")
ANESTHESIA: General.
INTRAVENOUS FLUIDS: [how much fluids] mL of crystalloid.
ESTIMATED BLOOD LOSS: [Estimated blood loss] mL (if not mentioned, put "0 mL")
DRAINS:
(if stent used, add: "[Stent size in F x stent length in cm] double pigtail ureteral stent")
(if stent with string used, add: "Stent string tether left in place")
LASER SETTINGS:
Laser type: [Laser type]
Settings: Power [Power] W, Frequency [Frequency] Hz, Pulse energy [Pulse energy] J.
(if dusting or fragmentation used, add: "[Dusting/Fragmentation] technique used")
(if laser settings not mentioned, omit this section please)
COMPLICATIONS: None.
INDICATIONS: [Patient name and age in conversational format] with a diagnosis of urolithiasis. [Additional information about patient and stone specifics if provided (otherwise omit)] The patient had extensive counseling about treatment options and, after ample opportunity to ask questions, elected to undergo ureteroscopy and laser lithotripsy.
The risks of the procedure were extensively discussed with the patient. Intraoperative risks included but were not limited to the following: bleeding, ureteral injury, perforation, infection, and need for additional procedures. Postoperative risks included but were not limited to urinary tract infection, stent discomfort, hematuria, and potential need for further interventions, ureteral stricture, etc. Cardiovascular risks included deep vein thrombosis, pulmonary embolus, myocardial infarction, stroke, and death were included in informed consent. The patient took opportunities to ask questions which I answered to the best of my ability. The patient wished to proceed.
OPERATIVE PROCEDURE IN DETAIL:
After proper informed consent was obtained, the patient was brought to the operating suite. Preoperative prophylactic antibiotics were administered. Satisfactory general anesthesia was established. The patient was positioned in the lithotomy position with great care to pad all bony prominences. After a sterile prep and drape, a procedural time-out was called using a standardized checklist.
(this paragraph is about access)
Cystoscopy was performed, and the bladder was inspected and found to be normal. The [left/right] ureteral orifice was identified, and a guidewire was advanced up the ureter under fluoroscopic guidance. The wire was secured to the drape as a safety wire. A second working wire was placed. All wires were 0.038 zip wires (if other wire type mentioned, then edit as appropriate).
(if retrograde pyelogram was performed, describe the retrograde)
(if rigid ureteroscope used, add: "A rigid ureteroscope was advanced over the guidewire using a double wire technique. Just for the duration of rigid ureteroscopy, a 14F foley was kept in the bladder to drain the ureteroscopic irrigant under pressure.")
(if flexible ureteroscope used without a sheath, add: "A flexible ureteroscope was advanced up to the level of the stone.")
(if ureteral access sheath used, add: "A ureteral access sheath (insert sheath diameter and length if mentioned) was placed fluroscopically prior to advancing the flexible ureteroscope, which was then passed to the level of the stone.")
The [likely stone type (if an observation about likely stone composition was mentioned, put that here as appropriate, otherwise keep it general)] stone was visualized and evaluated.
(if nephroscopy findings provided, add: "Nephroscopy findings: [nephroscopy findings].")
(this paragraph is about laser lithotripsy)
The Holmium laser (if a different laser type was used, mention that here, and insert fiber diameter if given) was used to fragment the stone. Settings included a power of [Power] W, frequency of [Frequency] Hz, and pulse energy of [Pulse energy] J (if laser settings not mentioned, just keep the description in general terms saying "Holmium laser lithotripsy was carried out to [fragment/dust} the stone. )
(if dusting used, add: "A dusting technique was utilized to break the stone into fine fragments.")
(if fragmentation used, add: "A fragmentation technique was used to break the stone into manageable pieces.")
(if basket used, add: "Stone fragments were retrieved using a tipless nitinol basket.")
Upon completion, the ureteroscope was withdrawn. The ureter was inspected for any residual stones or injury.
(this paragraph is about stent placement)
(if stent placed, add: "A [Stent diameter in French x length in cm] stent was placed for ureteral drainage, deployed in standard fashion with a good curl demonstrated proximally in the renal pelvis and distally under direct vision.")
(note that if a stent was placed completely fluoroscopically, that will be mentioned in the dictation, typically in a female patient, in which case use this language, "The stent was deployed fluoroscopically over the wire by holding the pusher at the urethral meatus and removing the wire, with a satisfactory proximal coil fluoroscopically. The beak of the scope was then inserted per urethra to push the distal end into the bladder, forming the distal coil, confirmed also on fluoro.")
(if stent with string placed, add: "A stent with a string was used for easier removal by the patient, secured to the pubic skin with steri strips.")
COMPLICATIONS: None.
The patient was awakened from anesthesia and transferred to the recovery room in stable and satisfactory condition. There were no immediate complications. I was present throughout.
PLAN: (mention the plan if discussed, otherwise omit)
s10.ai
[insert date and time of dictation in US format]"
Sample Clinical Note

Example of completed documentation using this template

DATE OF SURGERY: 11/01/2024
PATIENT: John Doe  
DOB: 05/15/1980  
MEDICAL RECORD NUMBER: 123456789  
SURGEON:  
s10.ai
ASSISTANTS:  
None
PREOPERATIVE DIAGNOSIS:  
Urolithiasis, 8 mm stone in the left distal ureter
POSTOPERATIVE DIAGNOSIS:  
Same
PROCEDURE:  
1. Cystoscopy  
2. Ureteroscopy and laser lithotripsy, left side. Stone size: 8 mm, Location: distal ureter  
3. Retrograde pyelogram
KEY DETAILS:  
Flexible ureteroscopy  
Ureteral access sheath used
ANESTHESIA: General.
INTRAVENOUS FLUIDS: 1000 mL of crystalloid.
ESTIMATED BLOOD LOSS: 0 mL
DRAINS:  
6F x 26 cm double pigtail ureteral stent
LASER SETTINGS:  
Laser type: Holmium  
Settings: Power 20 W, Frequency 10 Hz, Pulse energy 1.0 J.  
Dusting technique used
COMPLICATIONS: None.
INDICATIONS: John Doe, a 44-year-old male, with a diagnosis of urolithiasis. The patient had extensive counseling about treatment options and, after ample opportunity to ask questions, elected to undergo ureteroscopy and laser lithotripsy.
The risks of the procedure were extensively discussed with the patient. Intraoperative risks included but were not limited to the following: bleeding, ureteral injury, perforation, infection, and need for additional procedures. Postoperative risks included but were not limited to urinary tract infection, stent discomfort, hematuria, and potential need for further interventions, ureteral stricture, etc. Cardiovascular risks included deep vein thrombosis, pulmonary embolus, myocardial infarction, stroke, and death were included in informed consent. The patient took opportunities to ask questions which I answered to the best of my ability. The patient wished to proceed.
OPERATIVE PROCEDURE IN DETAIL:  
After proper informed consent was obtained, the patient was brought to the operating suite. Preoperative prophylactic antibiotics were administered. Satisfactory general anesthesia was established. The patient was positioned in the lithotomy position with great care to pad all bony prominences. After a sterile prep and drape, a procedural time-out was called using a standardized checklist.
Cystoscopy was performed, and the bladder was inspected and found to be normal. The left ureteral orifice was identified, and a guidewire was advanced up the ureter under fluoroscopic guidance. The wire was secured to the drape as a safety wire. A second working wire was placed. All wires were 0.038 zip wires.
A ureteral access sheath was placed fluroscopically prior to advancing the flexible ureteroscope, which was then passed to the level of the stone.
The stone was visualized and evaluated.
The Holmium laser was used to fragment the stone. Settings included a power of 20 W, frequency of 10 Hz, and pulse energy of 1.0 J. A dusting technique was utilized to break the stone into fine fragments.
Upon completion, the ureteroscope was withdrawn. The ureter was inspected for any residual stones or injury.
A 6F x 26 cm stent was placed for ureteral drainage, deployed in standard fashion with a good curl demonstrated proximally in the renal pelvis and distally under direct vision.
COMPLICATIONS: None.
The patient was awakened from anesthesia and transferred to the recovery room in stable and satisfactory condition. There were no immediate complications. I was present throughout.
PLAN: The patient will be monitored for any signs of infection or complications. Follow-up in the clinic in two weeks for stent removal.
s10.ai  
11/01/2024 14:30
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed for urologists and endourologists to efficiently document operative reports for procedures involving ureteroscopy and laser lithotripsy. It meticulously captures all essential details, from preoperative diagnosis to postoperative care, ensuring thorough and accurate documentation. The template includes sections for patient demographics, surgical team, detailed procedural steps, and specific variations in technique, such as the use of rigid or flexible ureteroscopes, laser settings, and stent placement. By incorporating high-search healthcare keywords, this template not only enhances clinical accuracy but also optimizes for search engines, making it an invaluable tool for clinicians seeking to streamline their documentation process. Adopt this template to ensure comprehensive, precise, and SEO-friendly operative reports that meet the highest standards of clinical documentation.
Frequently Asked Questions

Common questions about this template and its usage

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