URSL Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Ureteroscopic Lithotripsy

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

URSL is an endoscopic procedure performed through the natural urinary passage.

A semi-rigid or flexible ureteroscope is passed into the ureter to locate the stone.

The stone is fragmented using a laser or pneumatic Lithoclast probe.

Fragments may be removed using a basket or allowed to pass naturally.

A DJ stent may be placed at the end of the procedure.

4. Benefits and Indications

The procedure may be performed for:

• Ureteric calculus / ureter stone

URSL has a very high success rate for stones in the mid and lower ureter.

I understand that:

• If the stone migrates into the kidney, RIRS may be required at a later date.
• A DJ stent may require subsequent removal.

5. Risks and Complications

• Ureteric injury (1–2%)
• Stone migration
• Bleeding
• Hematuria
• Stent irritation (60–80%)
• UTI/Fever
• Renal colic
• Ureteric stricture (1–2%)
• Reflux

6. Postoperative Course

I understand that:

• Day-care surgery or overnight admission may be required.
• Blood in the urine may occur for several days.
• If a DJ stent is placed, stent-related discomfort, frequency and flank pulling sensation may occur.
• Small residual stone fragments may cause renal colic as they pass.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Medical expulsive therapy
• ESWL
• Laparoscopic ureterolithotomy
• 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: _________________________________________