Autologous Pubovaginal Sling Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Autologous Pubovaginal 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 strip of the patient’s own tissue, usually rectus fascia or fascia lata, is harvested and placed beneath the bladder neck or proximal urethra through a vaginal incision.

This requires a vaginal incision and an abdominal or thigh incision.

4. Benefits and Indications

The procedure may be performed for:

• Stress urinary incontinence due to intrinsic sphincter deficiency
• Recurrent SUI after previous surgery
• Cases where an autologous tissue sling is considered more appropriate than synthetic mesh

The intended benefits include:

• Improvement or cure of SUI
• Better bladder control
• Reduced urine leakage
• Improved quality of life
• No synthetic mesh implantation

Complete cure cannot be guaranteed.

5. Risks and Complications

• Common
  • Harvest-site pain
  • Temporary retention
  • Catheter requirement
  • UTI
  • Bruising and vaginal bleeding
• Less Common
  • Persistent retention
  • Urgency/frequency
  • Wound infection
  • Incisional hernia
  • Persistent donor-site pain
  • Dyspareunia
  • Recurrent SUI
• Rare but Serious
  • Significant bleeding
  • Bladder/urethral/bowel injury
  • Chronic pelvic pain
  • Deep infection
  • Sling revision
  • DVT/PE
  • Anaesthetic complications

6. Postoperative Course

I understand that:

• Hospital stay is usually 2–4 days.
• The catheter may remain for several days.
• Mild abdominal, vaginal or thigh discomfort may occur. Heavy lifting and intercourse should be avoided for 6 weeks.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Pelvic floor physiotherapy
• Lifestyle modification
• Continence pessary
• Urethral bulking injections
• Synthetic midurethral sling
• Burch colposuspension
• Artificial urinary sphincter
• 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: _________________________________________