Partial/Total Penectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Partial/Total Penectomy

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 procedure involves surgical removal of part or the entire penis depending on the extent of disease.

In partial penectomy, a penile stump is preserved to allow urination in the standing position where feasible.

In total penectomy, the entire penis is removed and a perineal urethrostomy is created for urination.

The removed specimen will be sent for histopathological examination.

4. Benefits and Indications

The procedure may be performed for penile cancer or other disease requiring removal of part or the entire penis.

The intended benefits include:

  • Removal of cancer
  • Local disease control
  • Prevention of disease progression and complications

No guarantee of cure or outcome can be given. Additional treatment such as lymph-node surgery, chemotherapy or radiotherapy may be required.

5. Risks and Complications

  • General Risks
    • Bleeding: approximately 2–10%
    • Infection: approximately 5–15%
    • Pain
    • Wound complications
    • Anaesthetic complications
  • Procedure-specific Risks
    • Wound breakdown/delayed healing: 10–20%
    • Urethral stenosis: 5–15%
    • Urinary spraying or difficulty urinating
    • Perineal urethrostomy complications
    • Infection or skin necrosis
    • Need for revision surgery
  • Functional and Psychosocial Risks
    • Loss of sexual function and erectile ability, complete after total penectomy
    • Infertility
    • Altered body image
    • Psychological impact
    • Impact on quality of life
    • Local or distant cancer recurrence
    • Need for additional surgery, including lymph-node dissection

6. Postoperative Course

I understand that:

  • Hospital stay: approximately 3–7 days, depending on recovery
  • Urinary catheter may remain for approximately 2–3 weeks
  • Wound care is essential
  • After total penectomy, urination occurs through the perineal opening, generally in the sitting position
  • Recovery may take approximately 3–6 weeks
  • Long-term follow-up is required

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Wide local excision
  • Glansectomy
  • Radiotherapy/brachytherapy
  • Laser or topical therapy for selected superficial lesions
  • No treatment, with associated risks explained

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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