Pediatric Bladder Stone Removal Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Endoscopic/Percutaneous Cystolithotripsy/Open Cystolithotomy

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

Depending on stone size, age, urethral calibre and anatomy, the stone may be removed:

  • Endoscopically through the urinary passage
  • Percutaneously through a suprapubic route
  • Through open cystolithotomy

The stone may be fragmented using appropriate energy or removed intact. A temporary urinary catheter may be required.

4. Benefits and Indications

This Procedure may be advised when a child has:

  • Pain during urination
  • Difficulty passing urine
  • Recurrent UTI
  • Blood in urine
  • Interrupted urinary stream
  • Urinary retention
  • Bladder irritation

The intended benefits include:

  • Untreated stones may enlarge and cause infection, bladder damage, obstruction or kidney damage.
  • Complete removal of bladder stones
  • Relief of urinary symptoms
  • Improved urine flow
  • Reduction in UTI
  • Prevention of stone-related complications

Removal of the stone does not necessarily correct the underlying cause of stone formation.

5. Risks and Complications

  • Common
    • Dysuria
    • Temporary haematuria
    • Mild lower abdominal pain
    • Catheter discomfort
    • Temporary frequency/urgency
    • Fever
  • Less Common
    • UTI
    • Residual stone fragments
    • Urinary retention
    • Wound infection
    • Prolonged catheter requirement
    • Additional endoscopic procedure
  • Rare but Serious
    • Significant bleeding/transfusion/re-operation
    • Urethral, bladder or ureteric-orifice injury
    • Bladder perforation
    • Urethral stricture
    • Vesicocutaneous urinary leak
    • Anaesthetic complications
    • Recurrent bladder stones
  • Procedure Specific
    • The surgical approach depends on stone size, urethral calibre, anatomy and intraoperative findings.
    • Laser, pneumatic, ultrasonic or other approved lithotripsy devices may be used.
    • More than one procedure may occasionally be required. A suprapubic catheter or DJ stent may be required.
    • If endoscopic treatment is not feasible or safe, conversion to percutaneous or open surgery may become necessary.

6. Postoperative Course

I understand that:

  • Hospital stay: approximately 1–3 days
  • Longer stay if open surgery is required
  • Temporary urinary catheter
  • Mild burning during urination
  • Blood in urine for a few days
  • Adequate oral fluids
  • Follow-up is necessary

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected asymptomatic patients
  • Endoscopic fragmentation
  • Percutaneous cystolitholapaxy
  • Open cystolithotomy
  • Temporary catheterisation in selected emergencies

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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