Pediatric Pyeloplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic / Open Pyeloplasty ± DJ Stent ± Nephrostomy

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 procedure is performed under general anaesthesia.

The narrowed PUJ segment is removed and the healthy ureter is reconnected to the renal pelvis to restore urine drainage.

A temporary DJ stent, drain and urinary catheter may be placed.

4. Benefits and Indications

The child has pelvi-ureteric junction obstruction (PUJO) causing impaired urine drainage from the kidney.

If untreated, obstruction may lead to:

  • Worsening renal function
  • Progressive kidney damage
  • Recurrent UTI
  • Pain
  • Stone formation

The intended benefits include:

  • Relief of obstruction
  • Preservation/improvement of kidney function
  • Reduction in pain and UTI
  • Improved renal drainage
  • Prevention of PUJO-related complications

Improvement in renal function depends on the extent of pre-existing damage.

5. Risks and Complications

  • Common
    • Operative-site pain
    • Fever
    • Temporary haematuria
    • Catheter discomfort
    • Temporary urine leakage around the drain
    • Wound discomfort
  • Less Common
    • Wound infection
    • UTI
    • Prolonged urinary leak
    • DJ-stent symptoms
    • Ileus
    • Prolonged drain requirement
  • Rare but Serious
    • Significant bleeding/transfusion/re-operation
    • Kidney, ureter, bowel, liver, spleen, pancreas or vascular injury
    • Anastomotic leak
    • Failure/recurrent obstruction
    • Loss of kidney function
    • Nephrectomy if the kidney is non-functional or irreparably damaged
    • Anaesthetic complications
  • Procedure Specific
    • Laparoscopic or open approach may be selected
    • DJ stent usually requires removal under anaesthesia after 4–8 weeks
    • Drain/catheter may be required
    • Conversion from laparoscopic to open surgery may be necessary
    • Additional reconstruction may be required for abnormal anatomy, crossing vessels, duplex systems or severe scarring
    • Nephrectomy may become necessary if the kidney is severely damaged/non-functional

6. Postoperative Course

I understand that:

  • Hospital stay: approximately 2–5 days
  • Temporary catheter and drain
  • Mild incision-site pain
  • Haematuria may occur for a few days
  • DJ-stent removal requires a separate procedure
  • Some pelvicalyceal dilatation may remain on follow-up ultrasound because established changes may not completely reverse

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected patients
  • Endopyelotomy
  • Temporary DJ stent
  • Percutaneous nephrostomy
  • Nephrectomy if the kidney is severely damaged and poorly functioning

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: _________________________________________

Related Posts