Laparoscopic Renal Cyst Deroofing Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Renal Cyst Deroofing

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 roof/wall of the renal cyst is excised laparoscopically.

The cyst contents are drained and part of the cyst wall is removed. The wall may be sent for histopathological examination where indicated.

4. Benefits and Indications

The procedure may be performed for a symptomatic or recurrent renal cyst causing:

  • Pain or discomfort
  • Pressure/mass effect
  • Other cyst-related symptoms

The intended benefits include:

  • Relief of pain/discomfort
  • Reduction in cyst size
  • Relief of pressure-related symptoms
  • Treatment of symptomatic/recurrent cyst

Complete symptom relief or prevention of recurrence cannot be guaranteed.

5. Risks and Complications

  • Common
    • Port-site pain
    • Abdominal discomfort
    • Mild haematuria where applicable
    • Nausea/vomiting
    • Temporary activity limitation
  • Less Common
    • Bleeding/haematoma
    • Transfusion
    • Kidney/collecting-system injury
    • Injury to surrounding organs
    • Cyst-content spillage
    • UTI
    • Wound infection
    • Urinary leak
    • Ileus
    • Conversion to open surgery
    • Persistent/recurrent symptoms
    • Cyst recurrence
    • Port-site hernia
    • DVT/PE
    • Additional procedure
  • Rare but Serious
    • Major bleeding
    • Major organ/vascular injury
    • Sepsis
    • Cardiovascular/respiratory complications
    • ICU care
    • Significant kidney injury
    • Life-threatening complications
    • Death

6. Postoperative Course

I understand that:

  • Cyst contents may spill during surgery. Histopathology may be performed when clinically indicated. Further management may be required if symptoms persist or the cyst recurs.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation for asymptomatic/uncomplicated cysts
  • Percutaneous aspiration ± sclerotherapy
  • Open cyst deroofing

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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