OT notes · Urology

Suprapubic cystostomy (open / trocar)

Usual anaesthesia
Local infiltration (trocar); local, spinal or general for open SPC
Position
Supine
Setting
emergency

Operative note template for suprapubic cystostomy by trocar or open method, with a filled example for a trocar SPC done under local anaesthesia for acute retention with failed urethral catheterisation.

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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

  • bleeding and blood in the urine
  • injury to bowel or peritoneum, higher if the bladder is not full
  • failure of trocar placement and conversion to open cystostomy
  • urine leak around the catheter
  • urinary and wound infection
  • catheter blockage or falling out
  • need for regular catheter changes
  • further surgery for the underlying cause (e.g. urethroplasty, prostate surgery)

Pre-operative details for this operation

  1. IndicationAcute retention, urethral catheterisation failedUrethral stricturePelvic fracture urethral injuryBladder injury at laparotomyLong-term drainage (neurogenic bladder)Otherhow many urethral attempts were made, by whom, and what happened
  2. Bladder full and palpableYes, dull to percussionConfirmed on ultrasoundNot full: open SPC planneda full bladder is required before a trocar SPC
  3. Retrograde urethrogram (if trauma)findings: partial / complete disruption
  4. Previous lower abdominal or pelvic surgery / scarsbowel may lie in front of the bladder
  5. Pelvic fracture fixation plannedNoYes: SPC site agreed with orthopaedics
  6. Anticoagulants / antiplateletsdrug and when last taken
  7. Renal functionserum creatinine, electrolytes

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationSpinalGeneralfor local: drug, strength and volume (plain lignocaine maximum 3 mg/kg)
  2. PositionSupine
  3. Bladder filling before punctureAlready distendedFilled with saline through a suprapubic needle / cannulaFilled through a fine feeding tube passed per urethra
  4. Ultrasound guidanceUsedNot used

Operative findings

  1. Urine drainedvolume in ml, colour (clear / cloudy / blood stained / pus)
  2. Bladder wall (open SPC)thickness, trabeculation, stones, growth, tear
  3. Bladder injury found (open SPC)NoneTear repairedBladder neck / base injurysite and size of any tear
  4. PeritoneumNot openedOpened and closed

Procedure (steps)

  1. Skin preparation and drapingantiseptic used
  2. Puncture / incision siteMidline, two finger breadths above the pubic symphysisMidline, one-third of the way from pubis to umbilicus (urethral distraction injury)Infraumbilical midline incision (open)Pfannenstiel (open)
  3. Confirmatory aspiration of urineneedle size; urine obtained before the trocar is passed
  4. Trocar: stab incision and linea alba nickedskin incision 5 to 10 mm
  5. Trocar and cannula passed into bladderdirection; free flow of urine on removing the trocar
  6. Catheter passed through the cannulaFoleyMalecotde Pezzersize in Fr; balloon volume
  7. Cannula removedSplit-sheath peeled awayWithdrawn over catheter
  8. Open: rectus sheath opened, recti separated, prevesical space enteredperitoneum pushed up, space of Retzius not dissected
  9. Open: bladder identified and openedstay sutures, urine aspirated first, vertical cystotomy at the dome
  10. Open: bladder inspectedstones, growth, injury; repair of any tear in two layers
  11. Open: catheter placed and purse-string tiedcatheter type and size, suture used
  12. Open: cystotomy closed around the catheterlayers and suture (e.g. polyglactin 2-0 in two layers)

Closure, drains and dressing

  1. Skinsuture around the catheter; suture material
  2. Rectus sheath (open)suture and technique
  3. Drain (open)NonePrevesical drain
  4. Catheter fixed to skinstitch or adhesive fixation
  5. Catheter connected to closed drainage bag
  6. Dressing

Specimens and implants

  1. Urine for culture and sensitivitySentNot sent
  2. Bladder biopsy / stones (open)Sent for HPE / stone analysisNot applicable
  3. Catheter detailstype, size (Fr), balloon volume, make and lot number

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. Urine outputhourly for the first few hours, then charted
  2. Urine colourwatch for blood or clots; report if the catheter stops draining
  3. Catheter careclosed drainage, bag below bladder level, site cleaned daily
  4. Vitalspulse, BP, temperature
  5. Abdomenwatch for pain, distension or guarding (possible bowel injury)
  6. Dietoral fluids when fully awake
  7. Analgesiadrug, dose, frequency
  8. Catheter change and further planplanned date of first change; plan for the underlying cause (e.g. urethroplasty after 2 months for pelvic fracture urethral injury)
  9. Patient teachingcatheter and bag care, in the patient's language, before discharge

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. S.P., 46 years, known anterior urethral stricture after a fall astride injury 3 years ago, with acute retention of urine for 10 hours. Two attempts at urethral catheterisation with a 14 Fr Foley failed in casualty.

Case details

Date: 04/05/2026. Emergency. Procedure room of casualty OT.

Start 23:10. End 23:30.

Surgeon: Dr A. (2nd-year resident, Surgery). Assistant: Dr B. (1st-year resident). Consultant Dr C. informed by phone.

No anaesthetist (local anaesthesia by surgeon). Nurse: Sr D.

Indication and pre-op

Indication: acute retention of urine. Two gentle attempts at urethral catheterisation with 14 Fr Foley failed, catheter held up at about 12 cm. No further urethral attempts made to avoid a false passage.

Bladder palpable up to 3 finger breadths below the umbilicus, dull to percussion. Bedside ultrasound: distended bladder, no bowel loop anterior to it.

No previous abdominal surgery. Not on anticoagulants. Serum creatinine 1.1 mg/dl.

Consent: procedure-specific consent in Marathi, including risk of bowel injury and conversion to open SPC.

Checklist done. Inj cefazolin 2 g IV at 23:00.

Anaesthesia and position

Supine. Parts painted with povidone-iodine and draped.

Local infiltration with 2% lignocaine 8 ml (160 mg; weight 68 kg) in the midline, skin down to the linea alba, two finger breadths above the pubic symphysis.

Procedure

Urine aspirated through the infiltration needle, confirming a full bladder.

Stab incision of 8 mm in the midline. Linea alba nicked with the blade.

Trocar and split-sheath cannula passed vertically downwards into the bladder. Clear urine flowed out on removing the trocar.

16 Fr Foley catheter passed through the cannula. Balloon inflated with 10 ml sterile water. Sheath split and removed. Catheter pulled back gently till the balloon rested on the bladder wall.

Findings: 1100 ml of clear, straw-coloured urine drained.

Closure

Skin closed with one polyamide (Ethilon) 2-0 stitch next to the catheter, and the catheter anchored to the skin with the same stitch.

Catheter connected to a closed drainage bag. Dry dressing.

End of procedure

Blood loss negligible (under 5 ml). No complications.

Urine sent for culture and sensitivity. No specimen for HPE.

Catheter: 16 Fr two-way silicone Foley, lot number copied from the pack and sticker pasted in the file.

Pulse 92/min, BP 138/84 mmHg. Pain relieved. Abdomen soft.

Post-op orders

Urine output hourly for 4 hours, then 4-hourly. Report blood clots, no drainage, or abdominal pain and distension.

Oral fluids allowed.

Oral analgesic as written on the drug chart.

Catheter care as per ward protocol. Patient and wife taught bag care in Marathi.

Urology OPD review in 2 weeks with a retrograde urethrogram to plan definitive treatment of the stricture.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 04/05/2026, 23:45.

Must document for this operation

  • Why a suprapubic route was chosen: how many urethral attempts, what size catheter, and where it stopped. Repeated blind urethral attempts can create a false passage, so the note must show that they were stopped after a reasonable trial.
  • How the bladder was shown to be full (palpation, percussion, ultrasound, aspiration of urine). A trocar passed into an empty bladder can enter the peritoneum or bowel, so this is the first thing checked after a complication.
  • Exact site of the SPC (distance above the pubis). In urethral injury the site matters for the later urethroplasty and for any pelvic fracture fixation.
  • Catheter type, size in French (Fr) and balloon volume. The ward staff need these for the first change, and a tract matched to the size makes changes easier.
  • Volume and colour of urine drained. This confirms the diagnosis of retention and is the baseline if haematuria appears later.
  • For open SPC: bladder findings and any repair. A tear, stone or growth seen at open cystostomy changes the plan and must reach the next surgeon.

Common mistakes in these notes

  • Writing 'SPC done' without the method (trocar or open) and catheter size.
  • Not recording how many urethral catheterisation attempts were made before the SPC.
  • No note of how the bladder was confirmed to be full before a trocar puncture.
  • Leaving out the volume of urine drained.
  • Missing the dose of local anaesthetic, so the maximum dose cannot be checked.
  • No written plan for the underlying cause or the date of catheter change.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. An SPC done in casualty still needs a full note. (NABH 5th ed., COP.14(e) and (f))
  • In NQAS-assessed public hospitals, the OT checkpoint 'Operative Notes are Recorded' looks for the people present, pre- and post-op diagnosis, procedure, length of procedure, blood loss, fluids, specimen and complications. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)

Sources

  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 25, Urological surgery for the general surgeon: percutaneous suprapubic cystostomy; suprapubic cystostomy (open), pp. 576-577.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 4A, Surgery of the skin: local anaesthesia (lidocaine maximum dose), pp. 43.
  • Keane TE, Graham SD Jr, eds. Glenn's Urologic Surgery. 8th ed. Wolters Kluwer; 2016, Ch 40, Surgery for urethral trauma including urethral disruption (Tausch TJ, Simhan J, Morey AF): open suprapubic catheter placement, e-book PDF pp. 607-608.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 5, Instruments: Malecot catheter and suprapubic cystostomy; Ch 27, Urologic surgeries: BPH, trocar SPC, pp. 102, 1096.
  • 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, lower tract instrumentation with risk factors and clean with entry into urinary tract: cefazolin among recommended agents. 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.

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

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