Buccal Mucosal Graft Urethroplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Buccal Mucosal Graft Urethroplasty

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 graft of buccal mucosa from the inner cheek or occasionally lower lip is harvested and used to reconstruct the narrowed urethra.

Depending on operative findings, the graft may be placed as a dorsal or ventral onlay.

4. Benefits and Indications

The procedure is indicated for female urethral stricture disease causing obstructive urinary symptoms when repeated dilatation or urethrotomy has failed or is unlikely to provide durable relief.

The intended benefits include:

  • Improved urinary flow
  • Better bladder emptying
  • Reduced recurrent UTI
  • Relief of obstructive symptoms
  • Improved quality of life
  • Durable long-term treatment

Recurrence may occur.

5. Risks and Complications

  • Common
    • Oral pain
    • Mild oral bleeding
    • Temporary catheter requirement
    • UTI
    • Dysuria
    • Vaginal discomfort
  • Less Common
    • Recurrent stricture
    • Persistent LUTS
    • Retention
    • De novo SUI
    • Wound infection
    • Oral numbness
    • Reduced mouth opening
    • Dyspareunia
  • Rare but Serious
    • Urethrovaginal fistula
    • Significant bleeding
    • Bladder/urethral injury
    • Parotid duct injury
    • Chronic oral pain/numbness
    • Chronic pelvic pain
    • Repeat urethroplasty
    • Anaesthetic complications
    • DVT/PE

6. Postoperative Course

I understand that:

  • Hospitalisation for approximately 3–5 days.
  • Urethral catheterisation for approximately 3–4 weeks.
  • Soft diet during the early recovery period.
  • Mouthwash and oral hygiene care.
  • Avoidance of strenuous physical activity during the early recovery period.
  • Avoidance of sexual intercourse for approximately 6–8 weeks.
  • Gradual return to normal activities over approximately 4–6 weeks.
  • Regular follow-up and assessment of urinary flow after catheter removal.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Direct Vision Internal Urethrotomy (VIU) – endoscopic incision of the scar.
  • Urethral dilatation – stretching of the narrowed segment.
  • Inner Preputial Graft (IPG) Urethroplasty – where suitable.
  • End-to-end anastomotic urethroplasty – for suitable short strictures.
  • Flap urethroplasty.
  • Permanent suprapubic catheter in selected patients.
  • No treatment, which may result in progressive obstruction.

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: _________________________________________

Related Posts