Cystoscopic Clot Evacuation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Cystoscopic Clot Evacuation

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 Cystoscopic Clot Evacuation is an emergency or semi-emergent endoscopic procedure.

A wide-bore cystoscope or resectoscope is passed through the urethra into the bladder.

Specialized suction devices, such as an Ellik evacuator or Toomey syringe, and continuous irrigation are used to break up and remove blood clots.

Once the clots are removed, the bladder is inspected and active bleeding points may be cauterized using diathermy.

4. Benefits and Indications

The procedure may be performed for:

  • Clot retention
  • Gross hematuria
  • Obstruction of the bladder by blood clots

The primary goals are:

  • Relief of painful bladder distension
  • Removal of obstructing blood clots
  • Control of active bleeding
  • Restoration of bladder drainage

A large 3-way urinary catheter will be placed after the procedure for continuous saline irrigation to prevent new clots from forming.

5. Risks and Complications

Intra-operative Complications

  • Bladder perforation (1–2%)
  • Temporary increase in bleeding
  • Incomplete evacuation of organized clots

Post-operative Complications

  • Recurrence of clots (10–20%)
  • UTI/Urosepsis
  • Bladder spasms

Long-term Complications

  • Urethral stricture

Patients taking blood thinners may have a significantly increased risk of re-bleeding.

6. Postoperative Course

I understand that:

  • Day-care surgery or overnight admission may be required.
  • A large 3-way urinary catheter is placed for continuous bladder irrigation following the procedure.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Manual aspiration
  • Continuous bladder irrigation (CBI)
  • Open cystotomy where endoscopic evacuation fails

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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