Double-J (DJ) Ureteric Stenting Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Double-J (DJ) Ureteric Stenting

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

A soft hollow plastic tube with curls at both ends is placed into the ureter using a cystoscope.

One end remains in the kidney and the other in the bladder, allowing urine to bypass an obstruction and drain from the kidney to the bladder.

Positioning is usually guided by X-ray/C-arm.

4. Benefits and Indications

The procedure may be performed for:

  • Ureteric obstruction
  • Hydroureteronephrosis
  • Pre-procedure preparation

The primary benefit is relief of pressure and obstruction of the kidney by allowing urine to drain freely.

I understand that the stent is a temporary internal drain and is not a permanent treatment for stones or strictures.

It must be removed or changed within the timeframe specified by the urologist, usually 4–12 weeks.

5. Risks and Complications

  • Failure to bypass obstruction
  • Ureteric injury
  • Malposition
  • Stent syndrome
  • Hematuria
  • UTI/Fever
  • Encrustation
  • Stent migration

Patients with pre-existing urinary infection have a higher risk of post-procedural fever or urosepsis.

6. Postoperative Course

I understand that:

  • Day-care surgery or overnight admission may be required.
  • Stent-related symptoms may include:
    • Frequency
    • Urgency
    • Flank discomfort during urination
    • Blood-tinged urine
  • These symptoms usually resolve after stent removal.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Percutaneous nephrostomy
  • Observation where appropriate
  • Definitive surgery such as URSL

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: _________________________________________

Related Posts