Patient Name: ______________________________ Age/Sex: ______________
UHID/Registration No.: ________________________ Ward/Bed No.: ________________
Consultant Surgeon: ________________________________________
Proposed Date of Surgery: ________________________________________
Device Brand/Model (if selected): ________________________________________

Informed Consent for Surgical Operation / Procedure

I, _______________________ (patient/next of kin/legal guardian), aged _____, sex M/F, in my full senses, authorize and give my complete consent for Inflatable Penile Prosthesis (IPP) implantation for __________________________.
Major illness & comorbidities: __________________________

 Authorisation for Procedure

I authorize Dr. __________ and such assistants and associates as may be selected by him/her to perform any part of the above procedure. Qualified members of the surgical team may perform parts of the procedure under appropriate supervision.

1. Diagnosis and Nature of Procedure
I have been informed that I have a condition of erectile dysfunction that has not responded adequately to, or is unsuitable for, non-surgical treatment options (oral medications, injection therapy, vacuum erection devices, or other conservative measures).
I have been advised to undergo surgical implantation of a malleable (semi-rigid) penile prosthesis. I understand this involves placement of a pair of bendable silicone rods into the erectile chambers (corpora cavernosa) of the penis through a surgical incision, performed under spinal/general anaesthesia, to allow me to achieve a rigidity sufficient for sexual intercourse by manually positioning the penis.

2. Alternative Treatment Options Explained
• Oral phosphodiesterase-5 inhibitor medications
• Intracavernosal or intraurethral vasoactive injections
• Vacuum erection devices
• Inflatable (multi-component) penile prosthesis as an alternative surgical option
• No treatment / observation
The relative benefits, risks, and expected outcomes of these alternatives have been discussed with me, and I understand why a malleable prosthesis has been recommended in my case.
3. Risks and Complications Explained
I understand that penile prosthesis surgery, like any surgical procedure, carries risks. These have been explained to me and include, but are not limited to:
• Infection of the implant, which may require partial or complete removal of the device (device-related infection risk, including rare but serious deep-seated infection)
• Mechanical failure, erosion, or extrusion of the device requiring revision or removal surgery in the future
• Persistent pain, or shortening/narrowing of the penis (decreased penile length or girth)
• Curvature, asymmetry, or altered cosmetic appearance of the penis
• Injury to the urethra, bladder, or adjacent structures requiring additional repair
• Bleeding, haematoma, or need for blood transfusion
• Altered or reduced penile/glans sensation
• Inability to achieve a fully natural-appearing erection; the device does not increase penile length beyond the pre-operative stretched length
• Anaesthesia-related risks, including cardiopulmonary complications
• Need for further surgery, including device revision, replacement, or removal, at any point in the future
• Persistent dissatisfaction with cosmetic or functional outcome despite a technically successful procedure
• Rare risk of penile prosthesis-related mortality or major morbidity
I understand that this list is not exhaustive and that unforeseen complications may occur.
4. Expected Benefits
I understand the intended benefit of this procedure is to restore the ability to have an erection adequate for penetrative sexual intercourse. I understand that outcomes vary between individuals and that no guarantee of a specific result has been made to me.
5. Anaesthesia
I have been informed that this procedure will require spinal or general anaesthesia, and I understand that a separate discussion and/or consent regarding anaesthesia risks will be/has been conducted by the anaesthesia team.
6. Intra-operative Decisions
I understand that during the course of surgery, unforeseen conditions may be discovered that may require the surgical team to perform additional or alternative procedures (including, if necessary, abandoning the planned implant) in my best interest. I authorize the surgical team to use their professional judgment in such circumstances.
7. Photography/Documentation
I consent to intra-operative photography or video documentation for medical records, quality assurance, and teaching/publication purposes, provided my identity is not disclosed.
8. Patient Acknowledgement
• I have been explained, in a language I understand, the nature of my condition, the proposed procedure, its risks, benefits, and alternatives.
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I understand that no guarantee has been made regarding the outcome of this procedure.
• I understand I may withdraw this consent at any time before the procedure begins.
• I voluntarily consent to undergo malleable penile prosthesis implantation surgery, and to any additional or alternative procedures the surgical team may deem necessary during the operation.
Patient Declaration
Signature: ______________________________
Name (block letters): ____________________________
Relationship to patient: ____________________ Date & Time: __________________
(If patient unable to sign / consent given by legal guardian or next of kin, state relationship and reason below)

Witness
Signature: ______________________________
Name (block letters): ____________________________
Relationship to patient: ____________________ Date & Time: __________________
Surgeon’s Declaration
I have explained the nature, purpose, benefits, risks, and alternatives of the proposed procedure to the
patient/guardian in a language understood by them, and have answered all questions raised.
Surgeon’s Signature: _________________________
Name: ______________________________ Date & Time: __________________