Percutaneous Nephrolithotomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Percutaneous Nephrolithotomy

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

PCNL is a keyhole procedure performed through a small incision of approximately 1 cm in the back/flank.

A tract is created into the kidney under fluoroscopy or ultrasound guidance.

A nephroscope is inserted to fragment and remove the stone.

A nephrostomy tube or DJ stent may be placed at the end of surgery.

4. Benefits and Indications

The procedure may be performed for:

  • Renal calculus/kidney stone
  • Staghorn calculus

The principal aim is maximum stone clearance.

I understand that a 100% stone-free rate cannot be guaranteed in a single sitting, particularly with large or complex stones.

A urinary catheter, DJ stent or nephrostomy tube may be required postoperatively for 1–5 days..

5. Risks and Complications

Intra-operative

  • Bleeding (5–10%)
  • Injury to adjacent organs (<1%)
  • Perforation of the pelvicalyceal system

Post-operative

  • Sepsis/infection (5–15%)
  • Fever
  • Urine leak
  • Retained stone fragments

Long-term

  • Chronic pain
  • Ureteric stricture
  • Stone recurrence

6. Postoperative Course

I understand that:

  • Day-care surgery or overnight admission may be required.
  • A urinary catheter, DJ stent or nephrostomy tube may remain for 1–5 days.
  • Residual stone fragments may require subsequent ESWL or RIRS.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • ESWL
  • RIRS
  • Medical management
  • Open/laparoscopic stone surgery
  • Observation

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: _________________________________________

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