Pediatric Ureteric Reimplantation for VUR Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic/Robotic Ureteric Reimplantation ± Tailoring ± DJ Stent

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 affected ureter is detached from its abnormal insertion and reimplanted into the bladder through an appropriate submucosal tunnel to prevent reflux while maintaining urinary drainage.

If the ureter is markedly dilated, tapering may be required.

A DJ stent, urinary catheter, suprapubic catheter and/or drain may be temporarily placed.

4. Benefits and Indications

The child has vesicoureteral reflux (VUR), in which urine flows backward from the bladder towards the ureter and kidney.

Untreated VUR may result in:

  • Progressive loss of kidney function
  • Recurrent UTI
  • Pyelonephritis
  • Renal scarring
  • Hypertension

The intended benefits include:

  • Prevention of urine reflux
  • Reduction in recurrent UTI
  • Prevention of further renal scarring
  • Preservation of kidney function
  • Improvement in quality of life

The surgery cannot reverse pre-existing renal damage or scarring.

5. Risks and Complications

  • Common
    • Operative-site pain
    • Temporary haematuria
    • Bladder spasms
    • Catheter discomfort
    • Fever
    • Temporary urgency/frequency
  • Less Common
    • Wound infection
    • UTI
    • Urinary leak
    • Persistent VUR
    • Temporary ureteric obstruction due to swelling
    • Prolonged catheter/drain requirement
    • Need for DJ stent
  • Rare but Serious
    • Significant bleeding/transfusion/re-operation
    • Bladder, ureteric, bowel, vascular or adjacent-organ injury
    • Ureteric obstruction
    • Anastomotic stricture
    • Persistent/recurrent VUR
    • Loss of kidney function
    • Repeat reimplantation
    • Nephrectomy in a severely damaged, poorly functioning kidney
    • Anaesthetic complications
  • Procedure Specific
    • The procedure may be open, laparoscopic or robotic.
    • Ureteric tailoring may be required for a markedly dilated ureter.
    • Bilateral reimplantation and reconstruction of associated congenital abnormalities may be required.
    • Conversion to open surgery may be necessary if minimally invasive completion is unsafe.

6. Postoperative Course

I understand that:

  • Hospital stay: approximately 3–7 days
  • Temporary urinary and/or suprapubic catheter
  • Mild lower abdominal pain
  • Temporary haematuria
  • DJ-stent removal may require a separate procedure
  • Follow-up may include ultrasound, VCUG and renal scan

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation with regular follow-up
  • Continuous antibiotic prophylaxis
  • Endoscopic Deflux/equivalent injection
  • Management of associated bladder and bowel dysfunction

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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