Laparoscopic Radical Nephrectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Radical 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 entire kidney is removed, usually with surrounding perinephric fat and Gerota’s fascia. The adrenal gland and/or regional lymph nodes may also be removed when clinically indicated.

The specimen is sent for histopathology.

4. Benefits and Indications

The procedure may be performed for appropriate renal tumours requiring removal of the entire kidney.

The intended benefits include:

  • Removal of renal tumour
  • Local disease control
  • Reduction of tumour-related complications
  • Treatment of potentially malignant renal mass

Complete cure or prevention of recurrence cannot be guaranteed.

5. Risks and Complications

  • Common
    • Port-site pain
    • Fatigue
    • Temporary abdominal discomfort
    • Nausea/vomiting
    • Reduced physical activity
  • Less Common
    • Bleeding/transfusion
    • Major vascular injury
    • Injury to bowel, liver, spleen or pancreas
    • Diaphragm/pleural injury
    • Adrenal injury
    • Wound infection
    • Chest complications
    • Ileus
    • Haematoma
    • UTI
    • DVT/PE
    • Conversion to open surgery
    • Port-site hernia
    • ICU requirement
  • Rare but Serious
    • Major haemorrhage
    • Major vascular/visceral injury
    • Sepsis
    • Cardiovascular/respiratory complications
    • Significant renal deterioration
    • Life-threatening complications
    • Death

6. Postoperative Course

I understand that:

  • After removal of one kidney, the remaining kidney provides the majority of renal function. Long-term renal function and blood pressure monitoring may therefore be required.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Active surveillance in selected cases
  • Partial nephrectomy where appropriate
  • Ablative treatment
  • Open radical nephrectomy
  • Systemic therapy in advanced 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: _________________________________________

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