OT notes · Urology

Pyeloplasty (open / laparoscopic Anderson-Hynes)

Usual anaesthesia
General
Position
Laparoscopic: 45 to 70 degree lateral decubitus; open: flank (lateral) with kidney rest, or prone for dorsal lumbotomy
Setting
elective

Operative note template for open or laparoscopic Anderson-Hynes pyeloplasty, with a filled example for a laparoscopic transperitoneal left pyeloplasty with a crossing lower pole vessel.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

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

  • urine leak from the anastomosis and prolonged drain
  • recurrent narrowing at the PUJ needing further surgery
  • DJ stent symptoms and a second procedure to remove it
  • injury to a crossing vessel, bowel, spleen or liver
  • urinoma or infection
  • conversion from laparoscopic to open
  • hydronephrosis may take months to improve on scans

Pre-operative details for this operation

  1. Side and diagnosisPUJ (UPJ) obstruction; symptoms (flank pain, infection, stones, falling function)
  2. Diuretic renogramdifferential function (%) and drainage (T1/2 or pattern)
  3. CT / CT urogram findingspelvis size, crossing vessel, stones, anomaly (horseshoe, malrotation)
  4. Existing drainageNoneDJ stent (date placed, date removed)Nephrostomy
  5. Urine cultureSterilePositive: organism, treated with (drug)
  6. Creatininevalue and date

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. Cystoscopy and retrograde pyelogram before main procedureDone: findingsNot done
  3. Stent routeRetrograde at cystoscopyAntegrade during repairNo stent
  4. Urethral cathetersize
  5. PositionLateral decubitus 45 to 70 degrees (laparoscopic)Flank with kidney rest and table flexed (open)Prone (dorsal lumbotomy)pressure points padded, arm support
  6. Orogastric tubePlacedNot placed

Operative findings

  1. Renal pelvisdegree of dilatation, thick / thin wall, extrarenal / intrarenal
  2. Cause of obstructionIntrinsic narrowing at PUJHigh insertion of ureterCrossing lower pole vesselUreteric stricture / polypCombination
  3. Crossing vesselartery / vein, relation to PUJ, preserved
  4. Ureter below the PUJcalibre, patency checked with feeding tube or wire
  5. Stones in pelvisNonePresent: number, removed

Procedure (steps)

  1. AccessLaparoscopic transperitonealLaparoscopic retroperitonealRobot-assistedOpen flank (anterior 12th rib tip)Open anterior subcostalOpen dorsal lumbotomyport sizes and sites / incision length
  2. Pneumoperitoneumentry method (Veress / open Hasson), pressure in mmHg
  3. ExposureColon reflected along line of ToldtTransmesenteric window (left)Extraperitoneal (open)
  4. Ureter, PUJ and pelvis dissectedureteric adventitia preserved; vessel loop or hitch stitch
  5. Type of repairDismembered (Anderson-Hynes)Y-V plasty (Foley)Fenger (Heineke-Mikulicz)Flap (Culp / Scardino)Ureterocalycostomy
  6. Pelvis reducedYes: amountNo
  7. Ureter transposed anterior to crossing vesselYesNot applicable
  8. Ureteric spatulationlateral side, length in cm
  9. Anastomosissuture material, size, continuous / interrupted, posterior wall then anterior wall
  10. DJ stentplaced before completion of anterior wall; size (Fr), length (cm); position confirmed (fluoroscopy / dyed saline in bladder)
  11. Pelviolithotomy (if stones)method, number of stones
  12. Haemostasis and coverpressure lowered to 5 mmHg to check bleeding; Gerota fascia / perirenal fat over repair
  13. Nephropexy (open, if kidney mobilised)DoneNot needed

Closure, drains and dressing

  1. DrainClosed suction (size Fr)PenroseNonesite, near but not on the anastomosis
  2. Port fascia12 mm or larger ports closed with (suture)
  3. Muscle layers (open)each layer separately, intercostal nerves not caught
  4. Skinsuture / glue
  5. Local anaestheticport sites or intercostal nerves: drug, strength, volume

Specimens and implants

  1. Excised PUJ segment and pelvisSent for HPENot sent
  2. StonesSent for analysisNone
  3. DJ stentmake, size (Fr), length (cm), lot number, sticker pasted, removal date

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. Drain outputrecord volume; drain fluid creatinine if output is high or looks like urine
  2. Urethral catheterkeep till POD 1 or 2 so the bladder does not back-pressure the repair
  3. Drain removalafter catheter removal and a void, if output stays low
  4. IV fluidsenough to hydrate; avoid heavy diuresis
  5. Diet and mobilisationorals as tolerated, mobilise from POD 1
  6. DJ stent removalat 4 to 6 weeks; date booked and written in discharge summary
  7. Follow-up imagingUSG at about 1 month; diuretic renogram at 3 to 6 months
  8. HPE reportreview in OPD

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

Worked example

Fictional case: Ms. N.J., 24 years, intermittent left flank pain, left PUJ obstruction with obstructed drainage on diuretic renogram and a lower pole crossing vessel on CT.

Case details

Date: 22/07/2026. Elective laparoscopic left Anderson-Hynes pyeloplasty. OT 3.

In OT 09:00. GA 09:10. Incision 09:45. Procedure ended 12:20.

Surgeon: Dr A. (Consultant, Urology). Assistant: Dr B. (3rd-year resident), did port placement, colon reflection and closure.

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Diuretic renogram: left split function 41%, obstructed drainage not relieved by furosemide. CT urogram: left extrarenal pelvis 3.5 cm AP, lower pole crossing artery anterior to PUJ, no stone.

No stent or nephrostomy in place. Urine culture sterile. Creatinine 0.8 mg/dl.

Consent: general, procedure-specific (including conversion to open, DJ stent, urine leak, recurrence) and anaesthesia consent taken in Hindi. Side marked.

WHO checklist done. Inj cefazolin 2 g IV at 09:30, before incision.

Anaesthesia and position

General anaesthesia with endotracheal tube. Orogastric tube placed. 14 Fr Foley catheter.

Right lateral decubitus at about 60 degrees, table partly flexed, pressure points padded. Abdomen painted with chlorhexidine-alcohol and draped.

Procedure

Veress at umbilicus, pneumoperitoneum 12 mmHg. Ports: 12 mm camera at umbilicus, 5 mm subcostal and 5 mm lower abdominal working ports, 5 mm assistant port.

Descending colon reflected along the line of Toldt. Gerota fascia opened near the lower pole. Ureter found medial to the gonadal vein and traced up to the PUJ, adventitia preserved.

Findings: dilated extrarenal pelvis. PUJ narrow with a lower pole artery crossing in front of it. Ureter below normal calibre. No stones.

Anderson-Hynes dismembered pyeloplasty. Pelvis incised above the PUJ and redundant pelvis marked for excision, left attached to the ureter as a handle. Ureter spatulated on its lateral side for 2 cm. Ureter and pelvis brought in front of the crossing artery, which was preserved.

Anastomosis with 4-0 polyglactin 910 (Vicryl): apical stitch from the lowest point of the pelvis to the apex of the spatulation, then continuous posterior wall.

Left DJ stent 6 Fr x 26 cm placed antegrade over a guidewire passed through a 14 G cannula below the costal margin. Upper coil in pelvis. Methylene-blue-stained saline instilled via Foley earlier seen refluxing up the stent, confirming lower coil in bladder.

Redundant pelvis and narrow PUJ excised. Anterior wall closed with continuous 4-0 Vicryl. Pelvis closed above the anastomosis. Funnel dependent, no tension.

Pressure dropped to 5 mmHg: no bleeding. Perirenal fat placed over the repair.

Closure

10 Fr closed suction drain placed near (not on) the anastomosis, out through the lower 5 mm port, fixed with Ethilon (polyamide) 2-0.

Umbilical 12 mm port fascia closed with absorbable suture. Skin closed with Monocryl (poliglecaprone) 4-0 subcuticular. Port sites infiltrated with 10 ml bupivacaine 0.5%.

Specimens and implants

Excised PUJ segment with redundant pelvis sent for HPE in formalin.

Left DJ stent: make ____, 6 Fr x 26 cm, lot no. ____, sticker pasted. Removal planned at 6 weeks (date written in discharge summary).

End of procedure

Estimated blood loss 50 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications. No conversion.

Extubated, shifted to recovery. Pulse 80/min, BP 118/76 mmHg.

Post-op orders

Vitals 1-hourly for 4 hours, then 4-hourly. Record drain output every 8 hours.

IV RL 1 L over 8 hours, then orals as tolerated. Mobilise on POD 1.

Foley till POD 2 morning. Remove drain after the patient voids if output stays low; send drain fluid creatinine if output is high.

Analgesia as per unit protocol.

DJ stent removal at 6 weeks. USG at 1 month, diuretic renogram at 3 to 6 months.

Signature

Dr B., JR-3, Urology, for Dr A. Reg. no. ________. 22/07/2026, 12:40.

Must document for this operation

  • Cause of obstruction found at surgery (intrinsic narrowing, high insertion, crossing vessel). It explains the choice of repair, and a missed crossing vessel is a known cause of failure.
  • Type of repair, whether the pelvis was reduced, and whether the ureter was placed in front of a crossing vessel. A surgeon doing a redo pyeloplasty needs to know exactly what was done the first time.
  • Anastomosis suture material, size and technique. It is part of the record of tissue altered and helps explain a later leak or stricture.
  • Double-J (DJ) stent size, length, lot number, and planned removal date. The stent must come out at 4 to 6 weeks; a forgotten stent encrusts.
  • Drain type, size and position. The ward team uses drain output to spot a urine leak.
  • Which steps the resident did and whether there was a conversion to open. The note must name who did the significant parts of the operation.

Common mistakes in these notes

  • Writing 'pyeloplasty done' without the type of repair or crossing vessel status.
  • Leaving out the stent length and removal date.
  • Not writing how the stent position was confirmed.
  • Not recording the drain size and site.
  • Not sending or not recording the excised PUJ segment.

Indian practice and paperwork

  • NABH asks that the batch and serial number of an implanted device go into the patient's record, the OT master logbook and the discharge summary. Paste the DJ stent sticker in the note. (NABH 5th ed., MOM.10(d))
  • Tissue removed and not sent for HPE is human anatomical waste for the yellow bag; discarded formalin from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Smith JA Jr, Howards SS, Preminger GM, Dmochowski RR, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 17, Open Pyeloplasty (Wiener); Ch 20, Laparoscopic and Robotic Pyeloplasty (Morgan, Soto-Palou), pp. 145-154, 174-181.
  • Smith JA Jr, Howards SS, Preminger GM, eds. Glenn's Urologic Surgery. 8th ed. Wolters Kluwer; 2016, Ch 10, Laparoscopic and Robotically Assisted Pyeloplasty in Adults; Ch 88, Pyeloplasty (Schober, Feber, Kass), e-book PDF pp. 171-181, 1221-1226.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV adult (3 g if 120 kg or more), within 60 min before incision. Table 2, urologic, clean with entry into urinary tract: cefazolin. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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