Flap Urethroplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Penile Skin Island Flap (Orandi / McAninch Technique)

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 longitudinal strip of penile shaft skin is raised as an island flap.

The flap remains attached to the underlying dartos fascia, which provides its blood supply.

The vascularised flap is then rotated or advanced to widen the narrowed urethral segment.

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

4. Benefits and Indications

The procedure may be performed for a urethral stricture requiring reconstruction with a vascularised penile skin flap.

The intended benefits include:

  • Well-vascularised urethral reconstruction.
  • Reduced risk of graft failure in appropriate cases.
  • No oral graft-harvest site. Avoidance of oral discomfort.
  • Suitability for moderate-length anterior urethral strictures.
  • Reported success rates of approximately 80–90%.

5. Risks and Complications

  • Common
    • Penile swelling and bruising.
    • Penile discomfort.
    • Urinary tract infection.
    • Catheter-related discomfort.
    • Temporary altered penile skin sensation at the flap-harvest site.
  • Less Common
    • Partial flap necrosis.
    • Urethrocutaneous fistula.
    • Stricture recurrence.
    • Wound infection.
    • Haematoma.
    • Penile skin scarring, tethering or altered texture.
  • Rare but Serious
    • Hair growth within the reconstructed urethra if hair-bearing skin is inadvertently included in the flap.
    • Recurrent urinary infection or urethral stone formation associated with hair-bearing tissue.
    • Failure of reconstruction.
    • Need for additional surgery.

6. Postoperative Course

I understand that:

  • A urethral catheter will remain for approximately 3–4 weeks.
  • Penile swelling and bruising may persist for several weeks.
  • The flap-harvest site requires wound care.
  • Urinary-flow assessment and regular follow-up are required.
  • Activity restrictions will be advised until adequate healing.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • BMG urethroplasty.
  • IPG urethroplasty.
  • End-to-end anastomotic urethroplasty for short strictures.
  • VIU or urethral dilatation.
  • Perineal urethrostomy in complex redo cases.

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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