Laparoscopic Distal Ureterectomy with Reimplantation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Distal Ureterectomy with Reimplantation

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 diseased distal ureter is removed, usually including the ureterovesical junction when required, and the remaining ureter is reimplanted into the bladder.

A DJ ureteric stent is usually placed temporarily. Removed tissue may be sent for histopathology.

4. Benefits and Indications

The procedure may be performed for:

• Distal ureteric tumour
• Ureteric stricture
• Ureteric obstruction
• Other localized distal ureteric disease

The intended benefits include:

• Removal of diseased ureteric segment
• Preservation of functioning kidney
• Relief of obstruction
• Improvement of urinary symptoms
• Reduction in recurrent infections
• Treatment of localized ureteric malignancy where applicable

Complete cure, preservation of kidney function or prevention of recurrence cannot be guaranteed.

5. Risks and Complications

• Common
  • Port-site pain
  • Temporary haematuria
  • DJ-stent symptoms
  • Nausea/vomiting
  • Temporary urinary symptoms
• Less Common
  • Bleeding/transfusion
  • UTI
  • Wound infection
  • Urinary leak
  • Ileus
  • Bladder, bowel or vascular injury
  • Reimplantation-site stricture
  • Prolonged stenting/nephrostomy
  • Port-site hernia
  • Conversion to open surgery
  • Re-operation
• Rare but Serious
  • Major bleeding
  • Major bowel/bladder/vascular injury
  • Sepsis
  • DVT/PE
  • Cardiopulmonary complications
  • Significant loss of kidney function
  • Residual/recurrent malignancy
  • Death

6. Postoperative Course

I understand that:

• A DJ stent will usually be removed later. Follow-up may include imaging, assessment of ureteric drainage and kidney function.
• Additional treatment may be required for urinary leak, stricture, recurrent obstruction or residual/recurrent disease. Duration of catheterization and hospital stay depends on postoperative recovery.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Observation
• Ureteroscopy/endoscopic treatment
• Balloon dilatation
• Open distal ureterectomy with reimplantation
• Segmental ureterectomy with ureteroureterostomy
• Radical nephroureterectomy, particularly for malignant disease

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: _________________________________________