Robot Assisted Radical Prostatectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Robot Assisted Radical Prostatectomy + Extended Pelvic Lymph Node Dissection

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 prostate is removed using a robotic surgical platform, along with pelvic lymph nodes as indicated.

The removed tissue will be sent for histopathological examination.

4. Benefits and Indications

The procedure is a definitive surgical treatment option for appropriately selected patients with prostate cancer.

Treatment choice depends on disease stage/aggressiveness, PSA, imaging, overall health, life expectancy and patient preference.

The intended benefits include:

  • Removal of prostate cancer tissue
  • Potential cure of localized prostate cancer
  • Possible relief of urinary obstruction
  • Oncological control

No guarantee of cure or treatment success can be given.

5. Risks and Complications

  • Intra-operative
    • Bleeding: 5–10%, with increased risk with blood-thinning medicines
    • Infection
    • Rectal injury: <1–2%
    • Ureteric injury
    • Increased wound/chest/heart/lung/thrombotic risk in obesity
    • DVT/PE
    • Heart attack or stroke
    • Pain
    • Need for ICU
    • Rare risk of death: <1%
  • Post Procedure
    • Temporary urinary incontinence; persistent incontinence: 5–10%
    • Erectile dysfunction: 30–70%
    • Lymphocele: 5–10%
    • Delayed bleeding up to approximately three weeks
    • Temporary bladder-muscle weakness/urinary retention
    • Urinary leak at the bladder-urethral junction
    • Urethral stricture
    • Hernia
    • Local or distant cancer recurrence
    • Need for adjuvant/salvage treatment

The robotic/keyhole procedure may need conversion to an open or laparoscopic approach requiring a larger incision.

Rare malfunction of the robotic system is also acknowledged.

6. Postoperative Course

I understand that:

  • Long-term monitoring is required because cancer may recur despite apparently complete surgical removal.
  • Histopathological examination of the removed tissue is required to determine the final pathology and further treatment plan.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Active surveillance, particularly for selected low-risk disease
  • Radiotherapy with hormonal therapy for appropriate intermediate/high-risk disease
  • Focal therapies such as HIFU, cryotherapy or laser ablation, which the source document describes as emerging options rather than standard care

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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