Join the Youth organization of USI - The Fastest Growing Chapter of Urological Society of India. Fill out the form today!
Informed Consent For Surgical Operation / Procedure
Procedure: Surgical Management of Ischemic Priapism
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
I consent to undergo emergency surgical treatment for ischemic priapism, including one or more corporal shunt procedures, and any additional procedures that may become necessary to preserve penile tissue, control bleeding, or ensure my safety.
The procedure is performed under general, spinal, or regional anaesthesia.
Depending on my condition, the surgeon may perform one or more of the following procedures:
1. Distal Corporoglanular Shunt
A small opening is created between the glans penis and the corpora cavernosa to allow trapped blood to drain.
Possible techniques include:
- Winter shunt
- Ebbehoj shunt
- T-Shunt
- T-Shunt with corporal tunnelling
- Al-Ghorab shunt
The exact technique will be selected according to the severity and duration of priapism and the surgeon’s judgment.
2. Corporal Tunnelling
If thick clotted blood prevents adequate drainage, a dilator or instrument may be passed within the corpora to remove obstructing thrombus and facilitate decompression.
3. Proximal Shunt
If distal shunt procedures fail to relieve the priapism, a proximal shunt, such as the Quackels procedure, may be required to create an alternative drainage pathway.
The decision to proceed to a proximal shunt will be made intraoperatively if clinically indicated.
4. Benefits and Indications
The procedure may be required for:
- Acute ischemic (low-flow) priapism
- Recurrent (stuttering) ischemic priapism
- Persistent ischemic priapism after failed aspiration and intracavernosal medication
The expected benefits include:
- Relief of painful prolonged erection
- Decompression of the corpora cavernosa
- Restoration of blood flow
- Prevention of further ischemic injury
- Reduction in corporal fibrosis
- Improved chance of preserving penile structure
I understand that the likelihood of preserving erectile function decreases significantly as the duration of ischemic priapism increases, particularly beyond 24–36 hours.
I understand that after 36–48 hours, many patients develop irreversible corporal smooth muscle damage despite technically successful surgery.
5. Risks and Complications
Although every effort is made to minimize complications, I understand that the following complications may occur.
Common Complications (>5%)
| Complication | Reported Frequency |
|---|---|
| Permanent erectile dysfunction | 30–90%* |
| Persistent corporal fibrosis (scarring) | 20–80% |
| Failure of initial shunt / persistent priapism | 10–30% |
| Recurrent priapism | 5–20% |
| Penile edema (swelling) | 10–40% |
| Penile bruising (ecchymosis) | 10–30% |
| Postoperative penile pain | 10–30% |
| Penile shortening due to fibrosis | 10–40% |
| Need for repeat shunt procedure | 5–20% |
| Need for penile prosthesis because of irreversible ED | 20–60% (especially when priapism exceeds 36–48 hours) |
*The incidence of erectile dysfunction increases dramatically as the duration of ischemic priapism increases.
Less Common Complications (1–5%)
| Complication | Reported Frequency |
| Wound infection | 1–5% |
| Hematoma | 2–10% |
| Persistent wound drainage | 1–3% |
| Delayed wound healing | 1–5% |
| Urinary retention | 1–3% |
| Glans sensory changes/numbness | 2–10% |
| Cosmetic dissatisfaction | 2–5% |
| Bleeding requiring return to theatre | 1–3% |
| Residual painful erection | 2–5% |
Uncommon Complications (0.1–1%)
| Complication | Reported Frequency |
| Urethral injury | <1% |
| Corporal perforation | <1% |
| Injury to dorsal nerves or vessels | <1% |
| Skin necrosis | <1% |
| Glans ischemia | <1% |
| Urethrocutaneous fistula | <1% |
| Permanent glans numbness | <1% |
| Chronic neuropathic penile pain | <1% |
Rare Complications (<0.1%)
| Complication | Reported Frequency |
| Glans necrosis requiring reconstruction | <0.1% |
| Severe uncontrolled hemorrhage | <0.1% |
| Deep vein thrombosis (DVT) | <0.1% |
| Pulmonary embolism | <0.1% |
| Myocardial infarction or stroke related to anaesthesia | <0.1% |
6. Postoperative Course
I understand that I should:
- Keep the dressing clean and dry.
- Take prescribed medications.
- Avoid sexual intercourse for 6–8 weeks.
- Avoid heavy lifting for approximately four weeks.
- Attend scheduled follow-up visits.
- Report immediately if I develop fever, severe pain, bleeding, wound discharge, inability to pass urine, increasing penile swelling, or black discoloration of the penile skin.
7. Alternatives to Procedure
I understand that ischemic priapism is a urological emergency and that delay in treatment may lead to permanent erectile dysfunction and irreversible penile damage.
8. Anaesthesia and Pain Management
I understand the risks associated with local, regional, or general anaesthesia.
Pain management options have been explained.
9. Photography / Data Use
I consent to:
☐ Medical photography/video for academic purposes
☐ Use of anonymized clinical data
10. Intraoperative Decision Consent
I authorize the surgeon to perform additional procedures considered necessary if unexpected findings arise during surgery.
11. Team-Based Care
I understand that supervised residents, fellows, or assistants may participate.
12. Patient Statement
I confirm that:
- The nature of surgery has been explained.
- Risks, benefits, and alternatives have been explained.
- My questions have been answered satisfactorily.
- I voluntarily consent.
Patient to write in own 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: _________________________________________