Laparoscopic Ureteric Reimplantation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Ureteric Reimplantation

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 ureter is reattached to the urinary bladder, usually after removal or bypass of a diseased segment.

Depending on the length and location of disease, a psoas hitch or Boari flap may be required.

A DJ stent is usually placed temporarily

4. Benefits and Indications

The procedure may be performed for:

• Ureteric obstruction
• Ureteric injury
• Ureteric stricture
• Reflux, where applicable
• Diseased ureteric segments requiring reconstruction

The intended benefits include:

• Relief of ureteric obstruction
• Preservation of kidney function
• Correction of ureteric injury/reflux where applicable
• Reduction in pain and recurrent UTI

Complete success and permanent ureteric patency cannot be guaranteed.

5. Risks and Complications

• Common
  • Abdominal/port-site pain
  • Haematuria
  • DJ-stent symptoms
• Less Common
  • Urinary leak
  • Wound infection
  • UTI
  • Recurrent ureteric stricture
  • Vesicoureteric reflux
  • Ileus
  • Additional stenting/dilatation/revision
  • Port-site hernia
• Rare but Serious
  • Major bleeding
  • Bowel/bladder/vascular injury
  • Sepsis
  • DVT/PE
  • Cardiopulmonary complications
  • ICU requirement
  • Death

6. Postoperative Course

I understand that:

• A DJ stent will usually be removed at a later date. Follow-up imaging and clinical evaluation are required to assess ureteric patency, drainage and kidney function.
• If the repair fails or obstruction recurs, additional endoscopic, radiological or surgical procedures may be required.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Endoscopic dilatation/endoureterotomy
• Long-term ureteric stenting
• Percutaneous nephrostomy
• Open ureteric reimplantation
• Robotic reimplantation
• Observation 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: _________________________________________