Cystoscopy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Cystoscopy (Rigid/Flexible)

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

Cystoscopy is a diagnostic procedure in which a thin, lighted cystoscope, either flexible or rigid, is inserted through the urethra into the bladder.

The procedure allows visualization of the urinary passage and bladder.

Additional minor procedures may include:

• Removal of small blood clots or stones
• Biopsy
• Removal of a DJ stent

4. Benefits and Indications

Cystoscopy may be performed for:

• Hematuria
• Recurrent urinary tract infection
• Lower urinary tract symptoms
• Follow-up of bladder mass

The primary benefit is direct, high-definition visualization of the urinary passage and bladder.

I understand that cystoscopy may not detect abnormalities hidden deep within the bladder wall or upper urinary tract unless combined with other investigations or procedures.

5. Risks and Complications

• Discomfort/pain
• Urethral trauma
• Inability to complete the procedure
• Dysuria
• Hematuria
• UTI (1–5%)
• Temporary urinary retention
• Urethral stricture (extremely rare)

If there is an active untreated UTI, the procedure may be postponed to reduce the risk of sepsis.

6. Postoperative Course

I understand that:

• Day-care surgery or overnight admission may be required.
• Mild burning during urination and light blood-tinged urine may occur for 24–48 hours.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Ultrasound
• CT Urogram
• MRI
• Urine cytology
• Observation

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: _________________________________________