Mid Urethral Sling Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Mid Urethral Sling (TVT/TOT/Single-Incision Sling)

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 narrow strip of synthetic mesh is placed beneath the middle portion of the urethra through a small vaginal incision, with or without small skin incisions depending on the technique.

The sling supports the urethra during increases in abdominal pressure.

4. Benefits and Indications

The procedure is performed for stress urinary incontinence causing urine leakage during coughing, sneezing, laughing, exercise or physical exertion.

The intended benefits include:

  • Improvement or cure of SUI
  • Reduced urine leakage during physical activity
  • Improved quality of life
  • Improved confidence and social functioning

Complete cure cannot be guaranteed.

5. Risks and Complications

  • Common
    • Temporary pain
    • Voiding difficulty
    • Catheter requirement
    • Urgency/frequency
    • UTI
    • Minor bleeding
  • Less Common
    • Persistent voiding difficulty
    • Mesh exposure
    • Persistent/recurrent SUI
    • Urgency incontinence
    • Dyspareunia and groin pain
  • Rare but Serious
    • Bladder/urethral/bowel injury
    • Major bleeding
    • Mesh erosion
    • Chronic pelvic pain
    • Retention requiring revision
    • Infection
    • Anaesthetic complications
    • Venous thromboembolism

6. Postoperative Course

I understand that:

  • Hospital stay is usually same day or 1 day.
  • Mild vaginal bleeding/discharge and temporary urinary discomfort may occur.
  • Heavy lifting and intercourse should be avoided for 4–6 weeks, followed by gradual return to normal activities.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Pelvic floor exercises
  • Pelvic floor physiotherapy
  • Lifestyle modification
  • Continence pessary
  • Urethral bulking agent
  • Autologous fascial sling
  • Burch colposuspension
  • Conservative management

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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