OT notes · Urology

Repair of bladder rupture and ureteric injury

Usual anaesthesia
General
Position
Supine, arms abducted (trauma laparotomy position)
Setting
emergency

Operative note template for repair of traumatic bladder rupture and ureteric injury, with a filled example for repair of an intraperitoneal bladder rupture at laparotomy after blunt trauma.

Download printable PDFFree. Just log in with your Google (Gmail) account.

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 repair
  • catheter for 7 to 10 days and a cystogram before removal
  • urinary infection and sepsis
  • clots in the bladder and blocked catheter
  • urgency and frequency after bladder repair
  • narrowing of the ureter after ureteric repair
  • DJ stent and a second procedure to remove it
  • fistula to bowel or vagina if those are also injured
  • staged repair or nephrostomy if too unwell for full repair

Pre-operative details for this operation

  1. MechanismBlunt (with / without pelvic fracture)PenetratingIatrogenic (during another operation)
  2. ImagingCT cystogramStatic cystogram with drainage filmsCT with delayed phase (ureter)Found at laparotomyintraperitoneal / extraperitoneal / both; bladder neck; ureteric level
  3. Type of bladder ruptureIntraperitoneal: needs operative repairExtraperitoneal, bladder neck spared: catheter drainage alone is an option; repair if laparotomy or pelvic fixation is done anywayExtraperitoneal with bladder neck involved: needs repairCombined intra- and extraperitoneal: needs repairNo bladder injury (ureter only)catheter alone: most extraperitoneal tears heal in 10 to 14 days, almost all by 3 weeks
  4. UrethraBlood at meatus: RGU done before catheterNo blood at meatus
  5. Indication for surgeryIntraperitoneal ruptureBladder neck lacerationPenetrating injuryPoor drainage with catheterRectal or vaginal injuryLaparotomy for other injuriesExtraperitoneal repair at pelvic fixationUreteric injury
  6. Haemodynamic status and other injuriesBP, pulse, blood given; pelvic fracture, bowel, vaginal injury
  7. Vaginal examination (female with pelvic fracture)Done: no lacerationDone: laceration foundNot applicable

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine, arms abducted
  3. Urethral cathetersize, placed before or during surgery

Operative findings

  1. Free urine / blood in peritoneumvolume
  2. Bladder lacerationsite (dome / lateral wall / bladder neck / trigone), length in cm, edges viable or not
  3. Second bladder woundNone found from insideExtraperitoneal tear foundExit wound found (penetrating)
  4. Ureteric orificesClear efflux both sidesNo efflux / bloody efflux: ureter explored
  5. Ureteric injuryside, level (proximal / mid / distal), partial or complete, length lost
  6. Other injuriesbowel, rectum, vagina, pelvic haematoma (not opened), bone spicules

Procedure (steps)

  1. IncisionMidline laparotomyPfannenstiel (at pelvic fixation)
  2. Peritoneal cavity cleared and surveyedurine and blood suctioned; other organs checked
  3. Space of RetziusNot opened (pelvic haematoma left alone)Opened after pelvic fixation
  4. Bladder inspected from insidelaceration extended if small; clots and bone spicules removed
  5. Bladder neck / extraperitoneal tear repaired from insidesuture and technique
  6. Edges debrided and bladder closedtwo layers, suture and size
  7. Leak testvolume of saline through catheter; extra sutures if leak
  8. Ureter exposed and injury assessedcolon mobilised along white line of Toldt; minimal dissection around ureter
  9. Ureteric repairSpatulated end-to-end anastomosis over DJ stentReimplantation into bladder (antirefluxing tunnel)Psoas hitch with reimplantationDamage control: ends ligated and taggedDamage control: external ureteric catheterNot injuredsuture size and interrupted / running; stent size
  10. Omental flap / tissue coverNot neededPlaced between repair and bowel / vaginal / rectal repair
  11. Suprapubic catheterNot placedPlaced (reason)

Closure, drains and dressing

  1. DrainPelvic / retroperitoneal drainNoneposition and size
  2. Peritoneal lavagevolume of warm saline
  3. Abdominal closuresuture and technique
  4. SkinStaplesInterruptedLeft open (contaminated)
  5. Catheter at endsize, balloon volume, urine colour

Specimens and implants

  1. SpecimenNoneDebrided tissue for HPEUrine / fluid for culture
  2. DJ stent (if ureteric repair)make, size, length, lot number, sticker; removal date
  3. External ureteric catheter / nephrostomyNoneDetails

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. Monitoringpulse, BP, urine output hourly; ICU if polytrauma
  2. Urethral catheterfree drainage; keep 7 to 10 days
  3. Clot retentioninform surgeon if catheter drains poorly or urine stops
  4. Drainoutput each shift; remove when output is minimal
  5. Cystogramstatic cystogram at 7 to 10 days before catheter removal; always for complex or trigone repairs
  6. Antibioticdrug, dose, duration
  7. DJ stent (ureteric repair)remove at 4 to 6 weeks, then IVU or retrograde study; ultrasound or IVU again at 3 months
  8. Other injuriesorthopaedic and surgical plans for associated injuries

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: Mr. H.K., 34 years, pillion rider in a crash after drinking, with lower abdominal pain, gross haematuria and inability to pass urine. No pelvic fracture. CT cystogram shows contrast around bowel loops from a dome tear. Haemodynamically stable.

Case details

Date: 18/08/2026. Emergency laparotomy and repair of intraperitoneal bladder rupture. Emergency OT.

Decision 16:10. In OT 16:45. Induction 16:50. Skin incision 17:00. Closure completed 18:10.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: intraperitoneal bladder rupture on CT cystogram (contrast outlining bowel loops). No extraperitoneal leak seen.

No blood at the meatus. Foley 18 Fr passed in casualty, 150 ml of bloody urine.

Hb 12.8 g/dl. Pulse 96/min, BP 124/80 mmHg. FAST: free fluid in pelvis. No other injury on CT.

Consent: written consent for laparotomy and bladder repair from patient in Hindi, with brother as witness.

Tetanus toxoid given in casualty. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 16:52.

Anaesthesia and position

General anaesthesia. Supine, arms abducted. Parts painted with povidone-iodine from nipples to mid-thigh and draped.

Procedure

Lower midline incision from umbilicus to pubis. About 700 ml of blood-stained urine in the peritoneal cavity, suctioned.

Survey: small bowel, colon, mesentery, liver, spleen normal. No pelvic haematoma. Space of Retzius not opened.

Findings: 5 cm ragged tear at the bladder dome, edges bruised.

Tear used to look inside the bladder. Clots removed. No second tear. Bladder neck intact. Both ureteric orifices seen with clear efflux.

Bruised edges trimmed back to bleeding tissue.

Bladder closed in two layers with running 3-0 polyglactin 910 (Vicryl): mucosa first, then muscle.

Bladder filled with 250 ml saline through the Foley: small leak at one end closed with a figure-of-eight 3-0 Vicryl. No further leak.

No suprapubic catheter.

Closure

Peritoneal cavity washed with 2 L warm saline. 28 Fr tube drain placed in the pelvis near the repair through a separate stab.

Linea alba closed with continuous looped No. 1 polydioxanone (PDS). Skin closed with staples.

Foley 18 Fr, balloon 10 ml, urine light pink.

Specimens and implants

No specimen. No implant.

End of procedure

Estimated blood loss 150 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse. WHO sign out done.

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 88/min, BP 120/76 mmHg.

Post-op orders

Pulse, BP and urine output hourly for 6 hours, then 4-hourly.

Foley on free drainage. Inform if urine stops or clots are seen.

Drain output each shift. Remove when output is minimal.

Nil by mouth till bowel sounds return. IV fluids as per chart. Analgesia as on drug chart.

Cystogram on POD 9. Remove Foley if there is no leak.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 18/08/2026, 18:25.

Must document for this operation

  • Type of rupture (intraperitoneal, extraperitoneal or both) and the site and size of the tear. The type decides whether repair was needed, and the next team uses the site to read the follow-up cystogram.
  • That the bladder was checked from inside for a second tear and the bladder neck. A missed second wound or bladder neck tear causes a persistent leak, especially in penetrating injury.
  • Efflux from both ureteric orifices, or how the ureters were checked. A missed ureteric injury can lead to loss of the kidney, sepsis or death.
  • Whether the space of Retzius and a pelvic haematoma were left alone. Opening a pelvic fracture haematoma can cause heavy bleeding, and the orthopaedic team needs to know its state.
  • Layers, suture and leak test result. If the cystogram shows a leak, the team needs to know how the bladder was closed.
  • For ureteric injury: level, length lost, repair type, stent details, or damage-control plan. A staged repair or stent removal will be done later, often by another surgeon, and depends on this record.

Common mistakes in these notes

  • Writing 'bladder repaired' with no tear site, size or layers.
  • Not recording that the ureteric orifices were seen.
  • No catheter duration or cystogram plan in the post-op orders.
  • For damage-control ureteric ligation, not writing clearly that a second operation is planned.
  • Leaving out the RGU result when there was blood at the meatus.

Indian practice and paperwork

  • NQAS assessors check that tetanus prophylaxis is given when indicated. Record it in trauma cases. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E15.2)
  • If a DJ stent is placed, its batch and serial number must go in the record, the master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • When a bladder or ureteric injury is found during another operation, the repair is an extra procedure. Record whether it was covered in the written consent or done because it could not wait. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • NABH expects the operative note to be written before the patient is moved out of recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Keane TE, Graham SD Jr, eds. Glenn's Urologic Surgery. 8th ed. Wolters Kluwer; 2016, Ch 26, Vesical trauma and hemorrhage (Gridley CM, McClung CD), e-book PDF pp. 381-387.
  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 27, Urological trauma (Best C, Varga S): ureter injury, bladder injury, pp. 516-529.
  • 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), started within 60 min before incision. Table 2, urologic, clean with entry into urinary tract: cefazolin. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf

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.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.