Augmentation Cystoplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Augmentation Cystoplasty (Bladder Augmentation)

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 segment of intestine, usually ileum, is used to enlarge the bladder, increasing bladder capacity and reducing storage pressure.

Additional reconstructive procedures may be required depending on operative findings.

4. Benefits and Indications

The procedure may be performed for:

  • High-pressure urine storage
  • Urinary incontinence
  • Recurrent urinary tract infections
  • Vesicoureteral reflux
  • Impaired bladder emptying
  • Risk of kidney damage despite conservative treatment

The intended benefit is:

  • Increased bladder capacity
  • Reduced bladder pressure
  • Protection of kidney function
  • Improved continence
  • Improved quality of lif

Complete symptom relief cannot be guaranteed.

5. Risks and Complications

  • Common
    • Pain
    • Bleeding
    • UTI
    • Wound infection
    • Ileus
    • Mucus production
    • Prolonged catheterization
    • Need for CIC
  • Less Common
    • Transfusion
    • Urinary leak
    • Bowel obstruction
    • Persistent incontinence
    • Bladder stones
    • Recurrent UTI
    • Incisional hernia
    • Metabolic abnormalities
  • Rare but Serious
    • Bowel, ureteric, bladder or vascular injury
    • Leak requiring reoperation
    • Peritonitis
    • DVT/PE
    • Severe bleeding
    • Metabolic acidosis
    • Electrolyte disturbances
    • Vitamin B12 deficiency
    • Renal deterioration
    • Bladder perforation
    • Malignancy in augmented bladder
    • Death, extremely rarelybsorption

6. Postoperative Course

I understand that:

  • Hospital stay is usually 7–14 days.
  • Temporary catheters and drains are expected. Bowel function gradually returns, and bladder training and follow-up are essential.
  • Lifelong follow-up, regular bladder irrigation, and possibly permanent CIC may be required.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation
  • Behavioural therapy
  • Medications
  • Botulinum toxin injections
  • CIC
  • Sacral neuromodulation in selected patients
  • Urinary diversion
  • 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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