Appendivesicostomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Bladder Neck Closure With Mitrofanoff (Appendivesicostomy)

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

The bladder neck is surgically closed to prevent urine leakage through the urethra.

A continent catheterizable channel, usually using the appendix (Mitrofanoff), is created between the bladder and abdominal wall to allow clean intermittent catheterization (CIC). If the appendix is unavailable, another bowel segment may be used.

4. Benefits and Indications

The procedure may be performed for:

  • Severe urinary incontinence due to an incompetent bladder outlet
  • Neurogenic bladder
  • Complex bladder dysfunction
  • Urethral destruction
  • Failed previous procedures where continence cannot otherwise be achieved

The intended benefits include:

  • Improved urinary continence
  • Protection of the upper urinary tract
  • Improved bladder emptying through CIC
  • Improved quality of life

Complete success cannot be guaranteed.

5. Risks and Complications

  • Common
    • Pain
    • Bleeding
    • Infection
    • Urinary tract infection
    • Temporary catheter dependence
  • Less Common
    • Urinary leak
    • Wound problems
    • Stomal stenosis
    • Difficulty catheterizing the channel
    • Bladder stones
    • Persistent leakage
    • Bowel-related complications
  • Rare but Serious
    • Bowel, ureteric or vascular injury
    • Fistula
    • Failure of bladder neck closure
    • Channel loss
    • Anaesthetic complications
    • Thromboembolism
    • Need for reoperation

6. Postoperative Course

I understand that:

  • Hospital stay is generally several days.
  • Recovery includes:
    • Catheter care
    • Stoma care
    • CIC training
    • Regular follow-up
  • Lifelong CIC through the Mitrofanoff is usually required. Catheterization through the urethra may no longer be possible after bladder neck closure.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Conservative management
  • Indwelling catheter
  • Suprapubic catheter
  • Urinary diversion
  • Sling/artificial urinary sphincter in selected patients
  • Other reconstructive procedures

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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