Distal Hypospadias Repair Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic Orchidopexy ± Orchidectomy

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

The urethral opening is reconstructed toward the tip of the penis and the glans is reconstructed to provide an appropriate urinary opening and penile appearance.

A urethral stent or catheter is generally placed for approximately 7–14 days.

The source consent states that surgery is typically performed between 6 and 18 months of age under general anaesthesia.

4. Benefits and Indications

The procedure may be performed when one or both testes have not descended normally into the scrotum.

The intended benefits include:

  • Urethral opening at the tip of the penis.
  • Forward urinary stream.
  • Improved penile appearance.
  • Single-stage repair.
  • Reported success rate of approximately 85–95% for distal hypospadias without chordee.

5. Risks and Complications

  • Common
    • Penile swelling and bruising.
    • Catheter/stent-related discomfort.
    • Mild blood-stained urine or wound ooze
  • Less Common
    • Urethrocutaneous fistula: approximately 4–7% in primary
    • TIP repair. Meatal stenosis: approximately 3–7%.
    • Wound infection or breakdown: approximately 3–5%. Haematoma: less than 5%.
  • Rare but Serious
    • Urethral stricture.
    • Urethral diverticulum.
    • Glans dehiscence.
    • Cosmetic dissatisfaction.
    • BXO/lichen sclerosus affecting the repair.
    • Need for additional surgery
  • Procedure Specific
    • General anaesthesia will be used, with penile nerve or caudal block for pain control.
    • The catheter/stent remains for approximately 7–14 days.
    • A penile dressing will be applied.
    • The child should not manipulate the catheter or dressing. Long-term review is recommended until puberty.

6. Postoperative Course

I understand that:

  • Hospital stay of approximately 1–3 days.
  • Catheter/stent for 7–14 days.
  • Penile swelling settling over approximately 1–2 weeks.
  • Return to nursery/school after approximately 2–3 weeks.
  • Bathing in a tub after catheter removal.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • No surgery.
  • Delayed repair.
  • Two-stage repair in selected circumstances.

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: _________________________________________

Related Posts