Laparoscopic Partial Nephrectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Partial Nephrectomy

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 renal tumour is removed with a margin of normal kidney while preserving the remaining functioning renal tissue.

The renal blood supply may be temporarily clamped. The collecting system and kidney are repaired as required, and the specimen is sent for histopathology.

4. Benefits and Indications

The procedure may be performed for selected localized renal tumours.

The intended benefits include:

• Removal of renal tumour
• Preservation of functioning renal tissue
• Better preservation of long-term kidney function where appropriate
• Cancer control for localized renal tumours

5. Risks and Complications

• Common
  • Port-site pain
  • Temporary reduction in kidney function
  • Haematuria
  • Fatigue
  • Nausea/vomiting
• Less Common
  • Bleeding/transfusion
  • Delayed bleeding
  • Urinary leak
  • Urinoma/perinephric collection
  • Injury to surrounding organs
  • Renal vascular injury
  • Collecting-system injury
  • Infection
  • Ileus
  • Chest complications
  • DVT/PE
  • Drainage/stenting
  • Conversion to open surgery
  • Radical nephrectomy
• Rare but Serious
  • Major vascular injury
  • Severe haemorrhage
  • Significant loss of renal function
  • Sepsis
  • Cardiovascular/respiratory complications
  • ICU care
  • Life-threatening complications
  • Death

6. Postoperative Course

I understand that:

• A catheter, drain or ureteric stent may be temporarily required. Urinary leakage may require prolonged drainage, stenting or further intervention.
• Follow-up may include renal function testing, imaging and further treatment based on histopathology, surgical margins, tumour stage or recurrence.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Active surveillance
• Radical nephrectomy
• Cryoablation/radiofrequency ablation
• Open partial nephrectomy
• Robotic partial nephrectomy

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: _________________________________________