Ureteroscopy with Laser Lithotripsy (Ureteral / Renal Stone)
Right [left] [ureteral / renal] calculus, [X] mm at [proximal / mid / distal ureter / renal pelvis / lower pole], obstructive [/ symptomatic]
Same
Right [left] ureteroscopy with holmium laser lithotripsy [and stone basket extraction]
[***, MD/DO]
[Nurse/tech name]
General endotracheal [/ spinal / MAC]
The patient is a [age]-year-old [male / female] with a [X]-mm right [left] [ureteral / renal] calculus at the [location] presenting with [renal colic / obstructive uropathy / UTI with obstruction]. Stone was not amenable to [observation / ESWL] given [size / location / infection / obstruction]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The ureteroscope was advanced to the level of the stone without difficulty [/ with access sheath]. The stone was [X] mm, [tan / yellow / brown], [mobile / impacted in the ureteral wall]. Holmium laser lithotripsy reduced the stone to [fragments < 2 mm / dust]. The ureter was [normal / with mucosal edema / with perforation; none]. The kidney collecting system was [normal / with additional calyceal stones]. A [DJ stent] was placed for [ureteral edema / perforation / complete stone clearance not achieved].
The patient was positioned in the dorsal lithotomy position. The genitalia were prepped and draped. A [12/14-Fr] ureteral access sheath [/ no access sheath; sizes 10/12 to 14/16 Fr available] was placed over a [0.035-inch Sensor (Boston Scientific) or equivalent hydrophilic working wire] under fluoroscopic guidance. The working guidewire was advanced to the [renal pelvis].
A [flexible / semi-rigid] ureteroscope was advanced alongside [/ through] the access sheath to the level of the stone. The stone was visualized at [X], [X] mm, [tan / yellow] in color.
A [200-micron] holmium laser fiber was introduced through the working channel. Laser settings: [1.0-1.5 J / 8-10 Hz for fragmentation] [/ 0.2-0.5 J / 30-60 Hz for dusting]. Laser technique (fragmentation vs dusting) is operator-dependent and may be adjusted based on stone size, location, and system power. The stone was fragmented to [<2-mm pieces / dust]. [Stone fragments were retrieved with a [2.4-Fr NCircle / stone basket] and extracted.] Residual dust was irrigated out.
Fluoroscopy confirmed [no residual stone > 2 mm; aim for stone-free status per AUA 2025 guidelines]. The ureter and collecting system were inspected: [normal mucosa / mucosal edema]. A [6 Fr × 26-cm] double-J ureteral stent was placed under fluoroscopic guidance with the proximal coil in the renal pelvis and distal coil in the bladder. Stent position was confirmed. The guidewires were removed.
None
Stone fragments [if retrieved]: sent to stone analysis laboratory
Minimal
[Double-J ureteral stent in place] / None
The patient was taken to the PACU in stable condition. Post-operative KUB [/ CT] was obtained to confirm stent position. The stent was to be removed in [5-7 days] for uncomplicated ureteroscopy, or [2-4 weeks] if ureteral injury, edema, or retained fragments were noted. Stone metabolic workup was recommended for [recurrent stone formers].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** calculus, *** mm at ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left ureteroscopy with holmium laser lithotripsy
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/spinal/MAC
INDICATIONS: .PTAGE-year-old .PTSEX with *** mm *** stone at ***, obstructive/symptomatic. Consent obtained.
FINDINGS: Stone *** mm at ***, *** color, ***. Lithotripsy: fragmented to *** mm/dust. Ureter normal/***. DJ stent placed/not placed.
PROCEDURE:
Dorsal lithotomy. Genitalia prepped. [Access sheath *** Fr over Sensor wire.] Flexible/semirigid URS to stone level. *** mm stone visualized. Holmium laser *** J / *** Hz. Fragmented to ***. [Basket retrieval.] Fluoro: no residual >2 mm (AUA 2025 stone-free standard). Ureter inspected: ***. [DJ stent *** Fr × *** cm, proximal coil renal pelvis, distal coil bladder.] Position confirmed fluoro. Wires removed.
EBL: Minimal
SPECIMENS: Stone fragments to stone analysis
COMPLICATIONS: None
DISPOSITION: PACU. KUB stent confirmed. Stent removal *** days (5-7 days standard; longer if ureteral injury or retained fragments).
Signed: .ME, .MYDEGREE
.TODAYVariants
Percutaneous Nephrolithotomy (PCNL): Large Renal Stone
For a [staghorn / >2 cm] renal calculus not amenable to URS or ESWL, PCNL was performed. Under fluoroscopic guidance [/ ultrasound guidance], a [18-gauge] needle was used to access the [lower / upper / middle] pole calyx in the prone position. An [Amplatz 30-Fr] sheath was dilated over the wire. A [nephroscope] was passed and the stone was fragmented with [ultrasonic / holmium laser] lithotripsy. Fragments were suctioned and extracted. A [20 Fr] nephrostomy tube [/ tubeless PCNL with DJ stent] was left for drainage. PCNL is the procedure of choice for stones >2 cm or staghorn calculi, offering superior stone-free rates compared to ESWL.
Charting Tips
- Document whether a ureteral stent was placed and the indication (ureteral edema, perforation, incomplete stone clearance, infection, solitary kidney, or pre-existing obstruction).
- Document stone size and appearance before and after lithotripsy. The pre-treatment stone size establishes the indication, while the post-lithotripsy assessment (residual fragments, completeness of clearance) determines whether additional intervention is needed.
- Document laser settings (energy in joules, frequency in Hz). Fragmentation settings (1.0-1.5 J / 8-10 Hz) are standard for most stones. Dusting (0.2-0.5 J / 30-60 Hz) may be preferred for large or posterior calyceal stones where basket retrieval is difficult. Neither technique is universally superior; choice depends on stone location, size, and surgeon preference.
Documentation & Reimbursement Considerations
- Report Ureteroscopy with Laser Lithotripsy (Ureteral / Renal Stone) as the primary service when it is the definitive operation performed.
- Ureteral stent placement at the conclusion of ureteroscopy: the applicable service is bundled into ureteroscopy codes when performed at the same session. Do not bill separately.
- Global period is 0 days (endoscopic).
- Document: stone location (renal vs proximal/mid/distal ureter), size, number of stones treated, access sheath size, laser settings (energy, frequency), and stent placement. Aim for stone-free status; residual fragments greater than 2 mm in the ureter are considered treatment failure per AUA 2025 guidelines and should prompt shared decision-making about secondary intervention.
- Bilateral ureteroscopy in one session: bill each side separately with right- or left-side reporting; bilateral rates apply. Document each side as a separate procedure with its own indication.