Burch Colposuspension Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Burch Colposuspension

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

Permanent sutures are placed on either side of the bladder neck and proximal urethra and attached to the iliopectineal (Cooper’s) ligament to elevate and support the bladder neck.

The procedure may be performed through:

  • Open abdominal surgery
  • Laparoscopy
  • Robotic surgery

No synthetic mesh is used.

4. Benefits and Indications

The procedure may be performed for stress urinary incontinence causing leakage during:

  • Physical exertion
  • Coughing
  • Sneezing
  • Laughing
  • Exercise

The intended benefits include:

  • Improvement or cure of stress urinary incontinence
  • Better bladder control
  • Reduced urinary leakage during physical activity
  • Improved quality of life
  • Avoidance of synthetic mesh

Complete cure cannot be guaranteed.

5. Risks and Complications

  • Common
    • Surgical-site pain
    • Temporary catheter requirement
    • UTI
    • Mild bleeding
    • Temporary voiding difficulty
    • Urgency/frequency
  • Less Common
    • Persistent voiding difficulty
    • Wound infection
    • Pelvic haematoma
    • De novo urgency
    • Dyspareunia
    • Recurrent SUI
    • Incisional hernia.
  • Rare but Serious
    • Bladder/urethral/bowel/vascular/nerve injury
    • Major bleeding
    • DVT/PE
    • Chronic pelvic pain
    • Anaesthetic complications
    • Conversion to open surgery

6. Postoperative Course

I understand that:

  • Hospital stay is usually 2–4 days.
  • The urinary catheter usually remains for 1–3 days.
  • Mild abdominal discomfort and temporary urgency/frequency may occur. Heavy lifting and intercourse should be avoided for 6 weeks.Hospital stay is generally several days.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Pelvic floor exercises
  • Lifestyle modification
  • Continence pessary
  • Urethral bulking agent
  • Midurethral sling
  • Autologous pubovaginal sling
  • Artificial urinary sphincter
  • Conservative management

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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