VIU Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Visual Internal Urethrotomy

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

VIU is an endoscopic procedure performed through the penis/urethra.

A specialized urethrotome is inserted to reach the stricture.

A cold knife or laser fiber is used to make a precise cut through the scar tissue and widen the narrowed passage.

A urinary catheter is typically left in place for 3–7 days to allow healing.

4. Benefits and Indications

The procedure may be performed for:

• Urethral stricture / narrowing of the urinary passage

The intended benefit is immediate relief from urinary blockage and improvement in urinary flow.

I understand that VIU does not remove the underlying tendency of the urethra to form scar tissue.

The stricture may recur and self-catheterization or periodic dilation may be required to maintain the result.

5. Risks and Complications

• Intra-operative
  • False passage (1–3%)
  • Bleeding
  • Fluid absorption
• Post-operative
  • Urethral pain/burning
  • Infection
  • Extravasation
  • Hematuria
• Long-term
  • Recurrence of stricture (40–60%)
  • Erectile dysfunction (extremely rare)
  • Incontinence (very rare)

6. Postoperative Course

I understand that:

• Day-care surgery or overnight admission may be required.
• A urinary catheter is typically maintained for 3–7 days.
• I understand that self-catheterization or periodic dilation may be required following surgery to maintain the result.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Urethral dilation
• Urethroplasty
• Suprapubic catheterization
• Clean intermittent self-catheterization

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: _________________________________________