Open cystolithotomy

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

• pain from a lower abdominal wound
• wound infection or wound breakdown
• urine leak from the bladder closure
• catheter for about 1 to 2 weeks and a cystogram before removal
• bleeding and blood in the urine
• urinary infection
• accidental opening of the peritoneum
• stone may come back if the cause is not treated
• longer hospital stay than an endoscopic stone removal

Pre-operative details for this operation

1. Indication for open surgeryStone larger than 4 to 6 cmHard stoneFailed endoscopic removalConcomitant open procedure (prostatectomy / diverticulectomy)write the stone size and number from imaging
2. ImagingNon-contrast CTUltrasoundX-ray KUBstone size in cm and number; upper tracts (hydronephrosis?)
3. Cystoscopy findings (if done)prostatic lobes, diverticulum, stricture, mucosal lesion
4. Urine cultureresult and antibiotic course completed before surgery
5. Likely cause of stoneBladder outlet obstruction (BPH / stricture)Neurogenic bladderForeign body / suture / meshAugmented bladderNot yet known
6. Concomitant procedure planned and consentedNoneSuprapubic prostatectomyDiverticulectomyOther

Anaesthesia and position

1. AnaesthesiaSpinalGeneralCombined spinal-epidural
2. PositionSupine with slight table flexion
3. Urethral catheter on the sterile fieldsize in Fr; genitalia included in the prep
4. Bladder filled before openingvolume of sterile water or saline, catheter clamped

Operative findings

1. Stonenumber, size in cm, surface (smooth / spiculated), hard or soft
2. Bladder wallNormalTrabeculatedInflamed
3. Bladder mucosaany suspicious lesion, biopsied or not
4. Intravesical prostatic lobeAbsentPresent, size
5. Diverticulum / foreign bodyNonePresent, describe
6. Ureteric orificesseen, efflux clear

Procedure (steps)

1. Skin preparation and drapingantiseptic used; genitalia and lower abdomen in the field
2. IncisionLower midlinePfannenstiellength in cm
3. Rectus sheath divided, recti split in the midline
4. Space of Retzius developedblunt dissection; peritoneum kept intact, or state if opened and closed
5. Stay sutures on bladdernumber and suture, e.g. two stay sutures of 2-0 polyglactin 910 near the dome
6. CystotomyVertical, dome towards bladder neckenergy used (cautery); length; bladder emptied by suction
7. Stone removedIntact with stone forceps / ring forcepsIn fragmentsnumber of stones removed; all fragments cleared
8. Bladder inspectedmucosa, prostatic lobe, diverticulum, ureteric orifices
9. Concomitant procedure (if any)name it and describe separately
10. Suprapubic catheterNot placedPlaced through separate stab cystotomysize in Fr
11. Bladder closurelayers and suture: e.g. mucosa running 3-0 polyglactin 910, muscle running 2-0 polyglactin 910
12. Leak testvolume instilled through the catheter, leak or no leak

Closure, drains and dressing

1. DrainClosed suction drain in the retropubic spaceNonesize; fixed to skin with non-absorbable suture
2. Rectus sheathsuture material and technique, e.g. running No. 0 polydioxanone
3. SkinInterruptedSubcuticularStaples
4. Catheter drainage at endurethral catheter size and balloon volume; colour of urine

Specimens and implants

1. StoneSent for stone analysisGiven to patientNot sent
2. Bladder mucosal biopsy for HPENot takenTaken, site
3. Prostate / diverticulum for HPE (if concomitant procedure)Not applicableSent

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. Vitals and urine outputpulse, BP, urine output and colour of urine, at the frequency written by the surgeon
2. Urethral catheterkeep on free drainage; do not remove before the cystogram
3. Pelvic drainrecord output every shift; high output suggests a urine leak; remove when low, usually around 48 hours
4. Antibioticas per urine culture sensitivity, drug, dose, duration
5. Analgesiadrug, dose and frequency as on the drug chart
6. Oral intake and mobilisationliquids when bowel sounds return, early walking
7. Cystogrambefore catheter removal, at about 7 to 14 days
8. Stone cause work-upfollow up for the underlying cause (outlet obstruction, neurogenic bladder) to prevent recurrence

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