Laparoscopic Pyelolithotomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Pyelolithotomy

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 renal pelvis is opened laparoscopically, the stone is removed and the renal pelvis is repaired.

A DJ ureteric stent is usually placed temporarily. The stone may be sent for analysis.

4. Benefits and Indications

The procedure may be performed for renal stones located predominantly in the renal pelvis

The intended benefits include:

• Removal of renal pelvic stones
• Relief of obstruction and stone-related pain
• Treatment/prevention of stone-related infection
• Preservation of kidney function
• Avoidance of repeated endoscopic procedures in selected cases

Complete stone clearance and prevention of future stones cannot be guaranteed.

5. Risks and Complications

• Common
  • Port-site pain
  • Mild haematuria
  • DJ-stent symptoms
  • Nausea/vomiting
  • Temporary urinary symptoms
• Less Common
  • Bleeding/transfusion
  • UTI
  • Wound infection
  • Urinary leak
  • Injury to kidney/collecting system
  • Injury to bowel, spleen, liver or vessels
  • Difficulty removing stone
  • Ileus
  • Residual stone
  • Additional procedures
  • Conversion to open surgery
  • Port-site hernia
• Rare but Serious
  • Major bleeding
  • Major organ or vascular injury
  • Sepsis
  • DVT/PE
  • Cardiopulmonary complications
  • Significant renal deterioration
  • Major further surgery
  • Death

6. Postoperative Course

I understand that:

• A DJ stent, urinary catheter and/or drain may be temporarily required. Residual stone fragments may require URS/RIRS, SWL, PCNL, stenting or other intervention.

7. Alternatives to Procedure

I have been informed of alternatives including:

• SWL
• PCNL
• URS/RIRS
• Open pyelolithotomy
• Observation in selected cases

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: _________________________________________