Laparoscopic Ureterolithotomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Ureterolithotomy

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 ureter is opened through a small incision, the stone is removed and the ureter is repaired.

A DJ stent is usually placed temporarily.

4. Benefits and Indications

The procedure may be performed for selected ureteric stones, particularly large or impacted stones where this approach is considered appropriate.

The intended benefits include:

• Removal of a large/impacted ureteric stone
• Relief of obstruction
• Relief of pain
• Preservation of kidney function

Complete stone clearance and prevention of future stone formation cannot be guaranteed.

5. Risks and Complications

• Intra-operative
  • Bleeding
  • Ureteric tear or avulsion
  • Difficulty locating/retrieving stone
  • Stone migration
  • Bowel or vascular injury
  • Urine spillage
  • Conversion to open surgery
  • Infection
  • DVT/PE
  • Cardiopulmonary complications
  • ICU requirement
  • Rare risk of death
• Post-Operative
  • Pain
  • Urinary leak
  • Wound infection
  • UTI
  • Haematuria
  • DJ-stent symptoms
  • Ureteric stricture
  • Residual/recurrent stone
  • Ileus
  • Additional procedures
  • Port-site hernia

6. Postoperative Course

I understand that:

• The DJ stent will usually be removed later. Follow-up imaging or other evaluation may be required to confirm stone clearance, ureteric healing and adequate drainage.
• Residual stone, ureteric stricture or urinary leak may require further endoscopic, radiological or surgical treatment.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Medical expulsive therapy where appropriate
• Ureteroscopy with lithotripsy
• Shock-wave lithotripsy
• PCNL in selected cases
• Open ureterolithotomy

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: _________________________________________