Procedure: Procedure for Peyronie’s Disease

1. Patient Consent

I, _______________________ (patient/next of kin/legal guardian), aged _____, sex M/F, in my full senses, authorize and give my consent for performance of the following procedure(s)/operation(s)/treatment(s): __________________________ for __________________________.
Major illness & comorbidities: __________________________

2. Authorisation for Procedure

I authorize Dr. __________ and such assistants and associates as may be selected by him/her to perform the above procedure. Qualified members of the surgical team may perform parts of the procedure under appropriate supervision.

3. Nature of Procedure (Explained)

The Nesbit procedure corrects penile curvature by plicating ellipses of tunica albuginea on the convex side of the penis. Artificial erection may be induced to assess correction. Circumcision may be performed if indicated. The procedure may be performed with modified Yachia repair or Nesbit’s repair.Patients who have congenital penile curvature or Peyronie’s disease require this procedure.

4. Benefits and Indications

• Correction of penile curvature
• Improved penetrative intercourse
• Durable correction in appropriately selected patients

5. No Guarantee Clause

I understand that no guarantee has been given regarding complete correction, cosmetic outcome, erectile function or long-term durability. Additional treatment or revision surgery may be required. The penile curvature is improved with a correction factor of 0-10 degrees to improve the functional outcome of penetrative intercourse. The plaque of Peyronie’s disease may not be excised if deemed necessary. In some cases, the procedure can be combined with a prosthesis if there is pre existing erectile dysfunction.

6. Risks and Complications

General Risks:
• Bleeding
• Infection
• Pain and wound complications
• Anaesthetic complications

Procedure-specific Risks:
• Minimal Penile shortening
• Residual/recurrent curvature
• Erectile dysfunction
• Altered penile sensation
• Cosmetic dissatisfaction
• Palpable sutures/scar
• Need for revision surgery

7. Postoperative Course (Explained)

Usually day-care/overnight stay. Swelling and bruising are expected. Abstain from sexual activity for 4–6 weeks. Follow-up is essential.

8. Alternatives to Procedure

• Observation
• Penile traction therapy
• Intralesional injections
• Penile plication
• Plaque incision/excision with grafting
• Penile prosthesis in patients with ED

9. Blood Transfusion Consent

I consent to blood/blood product transfusion if required and understand the rare risks of transfusion.

10. Anaesthesia and Pain Management

Anaesthesia risks and pain management options have been explained.

11. Photography / Data Use

I consent to medical photography/video and use of anonymised data for academic purposes.

12. Intraoperative Decision Consent

I authorise the surgical team to modify or extend the procedure depending on intraoperative findings.

13. Team-Based Care

Qualified assistants/trainees may perform parts of the procedure under supervision.

14. Patient Statement

I have understood the procedure, risks, benefits and alternatives. My questions have been answered and I voluntarily consent.

Patient/Attendant handwriting:
“I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.”

______________________________

Signatures

Patient Name & Signature: _______________________
Date: __________ Time: __________

Doctor Name & Signature: _______________________
Date: __________ Time: __________

Witness Name & Signature: _______________________
Contact No.: __________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent: __________________
Attendant Name: __________________
Relationship: __________________
Signature: __________________