Inner Preputial Graft (IPG) Urethroplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic Orchidopexy ± Orchidectomy

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

A graft is harvested from the inner mucosal surface of the foreskin (prepuce).

This tissue is used to widen or reconstruct the narrowed urethral segment.

The procedure is particularly suitable when an intact, uncircumcised foreskin is available, or it may be performed at the time of circumcision.

A urethral catheter is generally left in place for 3–4 weeks.

Depending on the complexity of the stricture, the reconstruction may be performed as a single-stage or two-stage procedure.

4. Benefits and Indications

I have been advised to undergo IPG urethroplasty for a urethral stricture that is too long or complex for direct end-to-end repair.

The inner mucosal surface of the foreskin is used as the graft material.

The intended benefits include:

  • Restoration of urinary flow.
  • Durable urethral reconstruction.
  • Reported success rate of approximately 80–90%.
  • No oral graft-harvest site.
  • Avoidance of mouth pain or altered taste.
  • Use of the patient’s own local penile tissue.
  • Reduced need for repeated endoscopic procedures.

5. Risks and Complications

  • Common
    • Penile and perineal swelling/bruising.
    • Discomfort at the foreskin harvest site.
    • Post-micturition dribbling.
    • Urinary tract infection.
    • Catheter-related discomfort.
  • Less Common
    • Urethrocutaneous fistula.
    • Stricture recurrence/restenosis.
    • Partial graft loss or graft contracture.
    • Wound infection.
    • Haematoma.
    • Penile skin scarring or altered appearance at the harvest site.
  • Rare but Serious
    • These may include erectile dysfunction, significant infection, significant bleeding, failure of reconstruction and need for additional surgery.

I understand that recurrence or failure of the graft reconstruction may require:

  • Dilatation.
  • VIU.
  • Repeat urethroplasty.
  • Additional graft or flap reconstruction.
  • Other urinary diversion procedures when clinically required.

6. Postoperative Course

I understand that:

  • A urethral catheter will remain for approximately 3–4 weeks.
  • The penile and perineal wounds require appropriate care.
  • Swelling and bruising generally improve over several weeks.
  • Urinary-flow assessment and follow-up are required after catheter removal.
  • Sexual activity and strenuous activity should be avoided until the treating surgeon confirms adequate healing.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • BMG urethroplasty.
  • VIU.
  • Urethral dilatation.
  • End-to-end anastomotic urethroplasty for suitable short strictures.
  • Flap urethroplasty.
  • Permanent suprapubic catheter in selected patients.

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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