Procedure: Plaque Incision and Grafting 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 procedure involves exposing the Peyronie’s plaque, making an incision (or partial excision) in the plaque, and placing a biological or synthetic graft to restore penile straightness. Artificial erection testing is performed intraoperatively. If the biological graft is preferred, it may be taken from saphenous vein, a vein in the thighs which can act as a graft. A separate incision may be taken and sometimes, a vascular surgeon may be called for harvesting the graft. Synthetic grafts are generally available in form of bovine pericardial grafts which may be used. If there is pre existing erectile dysfunction, a penile prosthesis may also be inserted combined with the procedure.

4. Benefits and Indications

• Correction of complex penile curvature
• Better preservation of penile length than shortening procedures
• Improved sexual function in 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.

6. Risks and Complications

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

Procedure-specific Risks:
• Erectile dysfunction
• Residual/recurrent curvature
• Graft contracture/failure
• Infection
• Bleeding/hematoma
• Altered penile sensation
• Penile shortening or deformity
• Need for further surgery

7. Postoperative Course (Explained)

Hospital stay is usually 1–2 days. Temporary swelling and bruising are expected. Sexual activity should be avoided for 6–8 weeks. Regular follow-up is required.

8. Alternatives to Procedure

• Observation
• Penile traction therapy
• Intralesional injections
• Penile plication/Nesbit procedure
• Penile prosthesis in patients with significant 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: __________________