Posterior Urethral Valve Ablation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Cystoscopy and Endoscopic Posterior Urethral Valve Ablation/Valve Incision

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, a cystoscope is passed through the urinary passage without an external incision.

The obstructing valve is identified and incised/ablated using an appropriate endoscopic instrument.

Depending on findings, additional procedures such as urethral dilatation, bladder-neck incision, DJ stent placement, suprapubic catheterisation or vesicostomy may be required.

4. Benefits and Indications

Posterior urethral valve (PUV) is a congenital obstruction of the urinary passage.

Untreated obstruction can result in:

  • Chronic renal failure
  • Recurrent UTI
  • Poor bladder emptying
  • Urinary retention
  • VUR
  • Progressive renal damage
  • Bladder dysfunction

The intended benefits include:

  • Relief of bladder outlet obstruction
  • Improved urinary stream and bladder emptying
  • Reduction in UTI
  • Preservation of kidney function
  • Reduction in bladder pressure
  • Prevention of further kidney damage

Valve ablation cannot reverse pre-existing kidney or bladder damage, and long-term follow-up remains necessary.

5. Risks and Complications

  • Common
    • Mild haematuria
    • Burning during urination
    • Catheter discomfort
    • Fever
    • Bladder spasms
    • Temporary difficulty passing urine
  • Less Common
    • UTI
    • Incomplete valve ablation requiring repeat endoscopy
    • Urethral injury
    • Urethral stricture
    • Persistent poor urinary stream
    • Temporary urinary incontinence
    • Prolonged catheterisation
  • Rare but Serious
    • Significant bleeding
    • Bladder perforation
    • Urethral/bladder-neck/ureteric-orifice injury
    • Persistent bladder dysfunction
    • Progressive renal impairment despite successful ablation
    • Need for vesicostomy
    • Anaesthetic complications
  • Procedure Specific
    • Diagnostic cystoscopy is performed
    • Complete valve ablation may not be possible in one procedure
    • Repeat endoscopy may be required
    • A temporary urinary catheter is usually placed
    • Vesicostomy or suprapubic catheterisation may be required if bladder drainage remains inadequate
    • DJ stenting may be required for upper urinary tract obstruction
    • Additional treatment may be required for urethral stricture, bladder diverticulum, VUR or congenital abnormalities

6. Postoperative Course

I understand that:

  • Hospital stay: approximately 1–3 days, potentially longer depending on kidney function and drainage
  • Temporary urinary catheter
  • Mild haematuria for several days
  • Temporary burning during urination
  • Regular follow-up may include ultrasound, urine testing, renal-function testing, age-appropriate uroflowmetry, MCUG and renal scan

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Temporary urinary catheter drainage
  • Vesicostomy
  • Suprapubic catheterisation
  • Observation is generally not recommended because untreated PUV may result in progressive kidney damage

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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