Stage 2 Urethroplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Stage 2 Urethroplasty

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 previously laid-open urethral plate is reconstructed.

A buccal mucosal graft may be placed as an inlay, and the edges of the urethral plate are rolled and tubularised to create the new urethral channel.

The reconstructed urethra is covered with surrounding tissue and penile or perineal skin.

A urethral catheter or stent is generally placed for approximately 2–4 weeks.

4. Benefits and Indications

I have previously undergone Stage 1 urethral reconstruction.

I am now advised to undergo Stage 2 reconstruction, involving placement of a buccal mucosal graft and tubularisation to complete the reconstructed urethra.

The intended benefits include:

  • Completion of urethral reconstruction.
  • Restoration of voiding through the tip of the penis.
  • Elimination of the temporary voiding opening created during Stage 1.
  • Final urethral reconstruction.

5. Risks and Complications

  • Common
    • Penile/perineal pain, swelling and bruising.
    • Pain and swelling at the cheek graft-harvest site.
    • Temporary restriction of mouth opening.
    • Transient oral numbness.
    • Urinary tract infection.
    • Catheter-related discomfort.
  • Less Common
    • Urethrocutaneous fistula.
    • Meatal stenosis.
    • Wound infection.
    • Wound dehiscence/breakdown.
    • Re-narrowing of the reconstructed urethra.
    • Need for further surgical repair.

6. Postoperative Course

I understand that:

  • A urethral catheter or stent will remain for approximately 2–4 weeks.
  • Penile/perineal swelling and discomfort may occur.
  • Oral discomfort may occur if a buccal graft is harvested.
  • Catheter care instructions will be provided.
  • Follow-up will be required to assess healing and urinary function.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Remaining at Stage 1 with the temporary voiding arrangement.
  • Conversion to permanent perineal urethrostomy.
  • No further treatment.

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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