End to End Anastomotic Urethroplasty for PFUI Consent

Informed Consent For Surgical Operation / Procedure

Procedure: End to End Anastomotic Urethroplasty for PFUI

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

Through a perineal incision, scar tissue between the two ends of the disrupted urethra is removed.

The healthy urethral ends are then brought together and joined without tension.

Additional procedures may be required to bridge a longer defect, including:

  • Corporal separation.
  • Inferior pubectomy.
  • Supracrural rerouting.
  • Combined transpubic-transperineal approach.

A urethral catheter and suprapubic catheter are generally kept for approximately 4–6 weeks.

4. Benefits and Indications

I have been advised to undergo this surgery because a pelvic fracture has resulted in complete disruption of the urethra.

The condition may leave me unable to pass urine normally and dependent on a suprapubic catheter.

The objective of surgery is to restore continuity of the urethra and allow normal voiding.

The intended benefits include:

  • Restoration of normal urinary passage.
  • Elimination of the need for a permanent suprapubic catheter.
  • Urinary independence.
  • Significant improvement in quality of life.
  • Reported success rates of approximately 85–95% in high-volume reconstructive centres.

5. Risks and Complications

  • Common
    • Perineal pain, swelling and bruising.
    • Scrotal oedema and bruising.
    • Urinary tract infection.
    • Catheter-related discomfort.
  • Less Common
    • Perineal or scrotal numbness/altered sensation.
    • Wound infection or haematoma.
    • Urinary leakage from the anastomosis.
    • Recurrence of urethral stricture.
    • Penile shortening or altered penile axis following extensive reconstructive manoeuvres.
  • Rare but Serious
    • These include erectile dysfunction, severe infection, significant bleeding, urinary complications, injury to adjacent pelvic structures and failure requiring further reconstruction.
    • I understand that erectile dysfunction may already be present as a consequence of the original pelvic fracture injury and is not necessarily caused by the reconstruction.

I understand that recurrent stricture or other complications may require:

  • Endoscopic treatment.
  • Repeat urethroplasty.
  • Staged reconstruction.
  • Permanent suprapubic catheterisation.
  • Perineal urethrostomy.

6. Postoperative Course

I understand that:

  • A urethral catheter and suprapubic catheter may remain for 4–6 weeks.
  • A postoperative imaging study may be required before catheter removal.
  • Perineal swelling and discomfort may persist for several weeks.
  • Urinary flow will be assessed after catheter removal.
  • Long-term follow-up is required to monitor for recurrence.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Permanent suprapubic catheter.
  • Endoscopic core-through or laser procedures.
  • Staged reconstruction.
  • Other reconstructive procedures depending on the defect.
  • The source consent notes that endoscopic procedures have a low success rate for complete distraction defects.

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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