Graft Nephrectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Graft Nephrectomy

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

Graft nephrectomy involves surgical removal of a previously transplanted kidney.

Because previous transplantation can result in dense adhesions, inflammation, infection and vascular scarring, the procedure may be technically more difficult than a routine nephrectomy.

The operation is usually performed under general anaesthesia and may be performed through an open or minimally invasive approach depending on the clinical situation and safety considerations.

4. Benefits and Indications

The procedure may be performed because of:

  • Graft failure.
  • Rejection.
  • Infection.
  • Uncontrolled bleeding.
  • Graft intolerance syndrome.
  • Vascular thrombosis.
  • Persistent graft-related pain.
  • Malignancy.
  • Other complications involving the transplanted kidney.

The intended benefits include:

  • Removal of a failed or diseased transplant.
  • Control of infection, bleeding, pain or rejection-related symptoms.
  • Prevention of potentially life-threatening transplant complications.
  • Facilitation of further management, including dialysis.
  • Facilitation of future transplant planning.

No guarantee can be given regarding complete symptom relief, future transplant eligibility or prevention of recurrence.

5. Risks and Complications

  • Intra-operative
    • Bleeding: 10–30%
    • Blood transfusion: 10–25%
    • Major vascular injury involving iliac vessels, renal vessels or IVC: 3–10%
    • Injury to bowel, bladder, ureter, vessels, nerves or abdominal-wall structures: 2–10%
    • Difficult dissection because of adhesions, infection, fibrosis or inflammation.
    • Prolonged surgery.
    • Extension of incision or modification of surgical plan.
    • Injury to the native urinary tract or transplant structures.
    • Anaesthesia-related complications: <1–2%
    • DVT/PE: 1–3%
    • ICU care: 5–15%
    • Rare risk of death: <1–2%
  • Post-operative
    • Pain at the incision site.
    • Wound infection: 5–15%
    • Bleeding/haematoma/seroma: 5–10%
    • Urinary leak: 1–5%, if urinary structures are involved.
    • Bowel injury or delayed bowel-related complications.
    • Chest complications: 2–10% Ileus: 5–15%
    • Sepsis/persistent infection: 2–10%
    • Reoperation/interventional procedure: 5–15%
    • Incisional hernia: 2–10%
    • Delayed wound healing.
    • Readmission.
    • Scarring or cosmetic concerns.
  • Transplant and Renal-Failure Considerations
    • Following graft removal, I may become or remain dependent on dialysis unless another functioning transplant is present.
    • Graft nephrectomy may affect my immunological status and may result in sensitisation/antibody formation.
    • This may influence future transplant planning.
    • Immunosuppressive medications may need to be changed before or after surgery.
    • Graft removal may be necessary even if this means returning to or continuing haemodialysis/peritoneal dialysis.
    • The procedure may be life-saving or medically necessary in severe complications.

6. Postoperative Course

I understand that:

  • ICU monitoring.
  • Surgical drains.
  • Urinary catheter.
  • Intravenous lines.
  • Dialysis support.
  • Close postoperative follow-up.
  • Histopathological examination of the removed graft may be required.
  • Further treatment may depend on the final diagnosis, infection status or future transplant plan.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Conservative management/observation.
  • Medical treatment, including antibiotics.
  • Modification of immunosuppressive medication.
  • Dialysis.
  • Percutaneous drainage or radiological intervention in selected cases.
  • Partial or delayed surgical intervention where appropriate.

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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