Laparoscopic Vesicovaginal Fistula Repair Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Vesicovaginal Fistula Repair

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 fistula is identified and dissected. The tract is excised or closed, and the bladder and vaginal defects are repaired separately.

Omental or another tissue interposition flap may be used when indicated.

4. Benefits and Indications

The procedure may be performed to close an abnormal communication between the urinary bladder and vagina causing continuous urinary leakage.

The intended benefits include:

• Closure of the fistula
• Improvement/restoration of urinary continence
• Reduction in recurrent urinary infection
• Improved quality of life

Successful closure and complete restoration of continence cannot be guaranteed.

5. Risks and Complications

• Intra-operative
  • Bleeding
  • Bladder, ureteric, bowel or vaginal injury
  • Difficulty identifying/dissecting fistula
  • Ureteric injury requiring stenting or repair
  • Conversion to open surgery
  • Infection
  • DVT/PE
  • Cardiopulmonary complications
  • ICU requirement
  • Rare risk of death
• Post-operative
  • Pain
  • UTI
  • Wound infection
  • Haematuria
  • Urinary leakage
  • Persistent/recurrent VVF
  • Ureteric obstruction/stricture
  • Bladder urgency/frequency
  • Vaginal/pelvic complications
  • Additional procedures
  • Port-site hernia

6. Postoperative Course

I understand that:

• A urinary catheter is usually maintained after surgery to allow bladder healing.
• Follow-up examination and appropriate imaging/tests may be required to assess fistula closure, bladder healing and urinary continence.
• Persistent or recurrent fistula may require further endoscopic, radiological or surgical treatment.
• The source form also specifies that clinical information may be used for treatment, audit, teaching, academic and research purposes with confidentiality maintained.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Prolonged catheter drainage for selected recent/small fistulas
• Vaginal/transvaginal repair
• Open VVF repair
• Robotic-assisted repair

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: _________________________________________