Plaque Incision and Grafting for Peyronie’s Disease Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Plaque Incision and Grafting for Peyronie’s Disease

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

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 the 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 the 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

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 authorize 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: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

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