Bladder Neck Incision Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Bladder Neck Incision

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

I understand that BNI is an endoscopic procedure performed through the urethra (natural urinary passage).

A resectoscope is inserted to visualize the bladder neck, where the bladder joins the urethra.

The surgeon uses an electrical knife or laser to make one or two deep incisions in the bladder neck tissue to widen the opening and allow urine to flow more freely.

A urinary catheter is typically left in place for 1–2 days.

4. Benefits and Indications

BNI may be performed for:

  • Bladder neck obstruction
  • Bladder neck contracture

The primary aim of BNI is to improve the flow of urine.

BNI is a focused procedure intended to treat localized narrowing at the bladder neck.

I understand that the success of the procedure depends on the bladder’s ability to contract effectively.

5. Risks and Complications

Intra-operative Complications

  • Bleeding
  • Perforation of the bladder or urethral wall

Post-operative Complications

  • Hematuria
  • UTI/Fever
  • Temporary urinary retention
  • Retrograde ejaculation (15–25%)

Long-term Complications

  • Recurrence of contracture (10–20%)
  • Incontinence (extremely rare)

I understand that previous radiation or multiple prior surgeries may significantly increase the risk of recurrence.

6. Postoperative Course

I understand that a urinary catheter is typically left in place for 1–2 days following the procedure.

7. Alternatives to Procedure

The alternatives discussed include:

  • Medical management with alpha-blockers
  • Urethral/bladder neck dilation
  • TURP where appropriate
  • Clean intermittent self-catheterization (CISC)

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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