Pediatric Hypospadias Repair Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Hypospadias Repair ± Chordee Correction / Staged 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

Under general anaesthesia, the urethra is reconstructed to bring the urinary opening to the tip.

Chordee is corrected where present. The glans and surrounding tissues are reconstructed.

A urinary catheter/stent is usually left temporarily.

Foreskin may be reconstructed or removed depending on the operative plan and findings.

4. Benefits and Indications

The procedure may be performed when the urinary opening is located on the underside of the penis rather than at the tip.

The child may also have:

  • Chordee/penile curvature
  • Abnormal foreskin

Surgery aims to improve urinary function, straighten the penis, achieve an acceptable cosmetic appearance and facilitate normal sexual function in adulthood.

The intended benefits include:

  • Correction of urinary opening
  • Straightening of the penis
  • Improved urinary flow
  • Improved cosmetic appearance
  • Facilitation of normal sexual function

Complete restoration of normal anatomy and function cannot be guaranteed.

5. Risks and Complications

  • Common
    • Penile pain/swelling
    • Bruising
    • Mild bleeding
    • Bladder spasms
    • Catheter discomfort
    • Dressing discomfort
  • Less Common
    • Wound infection
    • UTI
    • Meatal stenosis
    • Urethral stricture
    • Glans dehiscence
    • Skin separation
    • Residual curvature
    • Unsatisfactory cosmetic result
  • Rare but Serious
    • Urethrocutaneous fistula
    • Complete breakdown requiring repeat surgery
    • Urethral diverticulum
    • Urethral obstruction
    • Skin/flap/graft loss
    • Partial glans necrosis
    • Significant bleeding/re-operation
    • Anaesthetic complications
  • Procedure Specific: The exact technique may include:
    • TIP urethroplasty
    • Onlay flap
    • Mathieu repair
    • Two-stage repair
    • Other reconstruction

A catheter/stent usually remains approximately 5–14 days.

Circumcision, buccal mucosal graft or other grafting may be required. A staged repair may be necessary if tissues are unsuitable for single-stage reconstruction.

6. Postoperative Course

I understand that:

  • Hospital stay: approximately 1–3 days
  • Catheter/stent temporarily
  • Penile dressing
  • Mild swelling and bruising
  • Blood staining of dressing or urine may occur
  • Regular follow-up is essential

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected mild cases
  • Delayed surgery
  • Staged repair
  • No treatment

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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