Laparoscopic Pyeloplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Pyeloplasty

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 narrowed/obstructed segment is removed and the ureter is rejoined to the renal pelvis to allow drainage of urine.

A DJ stent is usually placed temporarily.

4. Benefits and Indications

The procedure may be performed to relieve pelvi-ureteric junction (PUJ) obstruction.

The intended benefits include:

  • Relief of PUJ obstruction
  • Improvement/preservation of kidney function
  • Reduction in hydronephrosis
  • Relief of pain and urinary symptoms
  • Reduction in recurrent infection related to obstruction

5. Risks and Complications

  • Common
    • Port-site pain
    • DJ-stent symptoms
    • Mild haematuria
    • Nausea/vomiting
    • Temporary urinary symptoms
  • Less Common
    • Bleeding/transfusion
    • Urinary leak
    • UTI
    • Wound infection
    • Injury to bowel, spleen, liver or surrounding organs
    • Ureteric/renal pelvic injury
    • Ileus
    • Anastomotic narrowing/restenosis
    • Persistent/recurrent
    • PUJ obstruction
    • Additional procedures
    • Conversion to open surgery
    • Port-site hernia
  • Rare but Serious
    • Major bleeding
    • Major organ/vascular injury
    • Sepsis
    • DVT/PE
    • Cardiopulmonary complications
    • Significant deterioration of renal function
    • Major reconstructive surgery
    • Death

6. Postoperative Course

I understand that:

  • A DJ stent will usually remain temporarily. Follow-up is required to assess urinary drainage and kidney function. Persistent or recurrent obstruction may require endoscopic or surgical treatment.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected cases
  • Endopyelotomy
  • Balloon dilatation
  • Open pyeloplasty
  • Robotic pyeloplasty
  • Long-term ureteric stenting
  • Nephrostomy 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: _________________________________________

Related Posts