Ureterovaginal Fistula Repair Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Ureterovaginal Fistula Repair

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 damaged ureter is identified and repaired.

Depending on the location and length of the injury, ureteric reimplantation into the bladder may be required.

A psoas hitch or Boari flap may also be required.

A ureteric stent, bladder catheter and surgical drain may be temporarily placed.

4. Benefits and Indications

The procedure may be performed for an abnormal communication between the ureter and vagina causing:

  • Deterioration of kidney function
  • Continuous urinary leakage
  • Recurrent UTI
  • Flank pain
  • Obstruction

The intended benefits include:

  • Restoration of normal urinary drainage
  • Resolution of urinary leakage
  • Preservation of kidney function
  • Relief of symptoms
  • Improved quality of life

Complete success cannot be guaranteed.

5. Risks and Complications

  • Common
    • Pain
    • Bleeding
    • Infection
    • Urinary tract infection
    • Bladder Spasma
    • Temporary Hematuria
    • Catheter Discomfort
  • Less Common
    • Urinary leak
    • Ureteric Stricture
    • Vesicoureteral Reflux
    • Recurrent Fistula
    • Prolonged Stenting
    • Need for transfusion
  • Rare but Serious
    • Bowel, ureteric or vascular injury
    • Failure requiring repeat surgery
    • Loss of kidney function
    • Thromboembolism
    • Anaesthetic complications and death

6. Postoperative Course

I understand that:

  • The DJ stent usually remains for 4–8 weeks.
  • The urinary catheter usually remains for 7–14 days.
  • Imaging may be required before stent or catheter removal.
  • Hospital stay is usually 3–7 days. Regular follow-up and planned stent removal are essential.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Temporary ureteric stenting
  • Percutaneous nephrostomy
  • Observation in selected situations
  • Urinary diversion or 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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