Urethroplasty Using Martius/Labial Flap Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urethroplasty Using Martius/Labial Flap

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 flap of living tissue with its own blood supply is used to reconstruct the urethra or close a fistula.

Martius Flap

A pad of fatty tissue from the labium majus is harvested while maintaining its blood supply and transferred to the urethral repair site.

Labial Skin Flap

A flap of labial skin may be used for shorter urethral defects.

The procedure is performed through a transvaginal approach.

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

4. Benefits and Indications

The procedure may be performed for:Complex female urethral stricture.

  • Urethrovaginal fistula.
  • Recurrent or previously failed urethral reconstruction.
  • A flap-based repair is used when a well-vascularised tissue layer is preferred for reconstruction.

The intended benefits include:

  • Well-vascularised repair.
  • Reduced risk of repair failure and fistula.
  • Suitability for complex, recurrent or previously failed repairs.
  • Reported success rates of approximately 75–85% in complex cases.
  • Avoidance of an oral graft-harvest site.

5. Risks and Complications

  • Common
    • Pain, swelling and bruising at the labial harvest site.
    • Bleeding from the labial flap bed.
    • Labial lymphorrhoea.
    • Vaginal wound discomfort.
    • Urinary tract infection.
    • Catheter-related discomfort.
  • Less Common
    • Labial wound infection.
    • Haematoma.
    • Vaginal wound dehiscence/breakdown.
    • Partial flap necrosis or flap loss.
    • Recurrent urethral stricture.
    • Altered labial sensation.
    • Permanent change in labial appearance.
  • Rare but Serious
    • Persistent or recurrent urethrovaginal fistula.
    • Need for further reconstructive surgery.
    • New-onset urinary incontinence

I understand that recurrence, flap loss, fistula persistence or urinary complications may require:

  • Additional fistula repair.
  • Repeat reconstruction.
  • Urethral dilatation.
  • Endoscopic treatment.
  • Repeat flap or graft urethroplasty.

6. Postoperative Course

I understand that:

  • The urethral catheter may remain for approximately 3–4 weeks.
  • Labial and vaginal discomfort may persist for several weeks.
  • Swelling and bruising generally improve over 2–4 weeks.
  • The surgical wounds require appropriate hygiene and follow-up.
  • Further evaluation may be required before catheter removal.
  • Sexual intercourse and strenuous activity should be avoided until adequate healing has occurred.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Female BMG urethroplasty.
  • Urethral dilatation.
  • Long-term catheterisation.
  • No treatment.
  • I understand that urethral dilatation may provide temporary relief and has a high recurrence rate, while long-term catheterisation does not correct the underlying stricture.

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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