Laparoscopic Bladder Diverticulectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Bladder Diverticulectomy

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

Laparoscopic bladder diverticulectomy involves removal of the bladder diverticulum through small abdominal incisions.

The bladder opening is closed with sutures. A urinary catheter is usually kept temporarily until bladder healing is adequate. A drain or ureteric stent may be required depending on operative findings. Removed tissue may be sent for histopathological examination.

Conversion to open surgery may be necessary for safe completion.

4. Benefits and Indications

The procedure may be performed for:

  • Recurrent urinary tract infections
  • Difficulty emptying the bladder
  • Significant residual urine
  • Lower urinary tract symptoms
  • Urinary stasis Bladder stones
  • Haematuria
  • Large or symptomatic bladder diverticulum

The intended benefits include:

  • Removal of the diverticulum
  • Reduction in recurrent infections and urinary stasis
  • Improvement in bladder emptying
  • Improvement in urinary symptoms
  • Treatment of associated bladder stones where present
  • Prevention of further diverticulum-related complications

Complete relief of symptoms or restoration of normal bladder function cannot be guaranteed.

5. Risks and Complications

  • Common
    • Pain or discomfort
    • Mild haematuria
    • Temporary frequency, urgency or dysuria
    • Nausea/vomiting
    • Temporary urinary catheter
    • Port-site discomfort or scarring
  • Less Common
    • Bleeding/transfusion
    • UTI or wound infection
    • Urinary leak
    • Prolonged catheterization
    • Ileus
    • Injury to bladder, ureter, bowel or surrounding organs
    • Need for ureteric stenting
    • Persistent difficulty emptying the bladder
    • Persistent urinary symptoms
    • Port-site/incisional hernia
    • Need for additional procedures
    • Recurrence
  • Rare but Serious
    • Major bleeding
    • Major ureteric or bowel injury
    • Urinary fistula
    • Severe infection/sepsis
    • DVT/PE
    • Cardiovascular or respiratory complications
    • Need for intensive care
    • Major reconstructive surgery
    • Death

6. Postoperative Course

I understand that:

  • A urinary catheter will usually remain after surgery and may require imaging before removal. Ureteric stenting or other additional measures may be required depending on the relationship of the diverticulum to the ureter.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation / conservative management
  • Endoscopic treatment
  • Open bladder diverticulectomy
  • Treatment of the underlying cause without diverticulectomy
  • No treatment

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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