Radical Cystectomy with Ileal Conduit Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Robot-assisted/Open Radical Cystectomy + Ileal Conduit + Bilateral Standard Pelvic Lymph Node Dissection

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 operation involves:

• Removal of the urinary bladder and surrounding tissues
• In males, removal of the prostate and seminal vesicles as applicable
• In females, removal of the uterus/anterior vaginal wall as applicable
• Bilateral pelvic lymph-node dissection
• Creation of an ileal conduit using a segment of intestine
• Bringing the conduit out as a stoma on the abdominal wall
• Continuous drainage of urine into an external collection bag

4. Benefits and Indications

The procedure may be performed for appropriate bladder cancer requiring removal of the urinary bladder.

The intended benefits include:

• Removal of bladder cancer with curative intent where feasible
• Prevention of disease progression/spread
• Relief of haematuria, pain and obstruction

Cancer recurrence may still occur despite surgery.

5. Risks and Complications

• General Risks
  • Bleeding requiring transfusion
  • Wound, urinary or systemic infection
  • Pain and fever
  • DVT/PE
  • Myocardial infarction
  • Stroke
  • Anaesthetic complications, including rare death
• Procedure-specific Risks
  • Injury to bowel, ureters, blood vessels or nerves
  • Urinary leak
  • Ileus
  • Bowel obstruction
  • Bowel leak/fistula
  • Stomal retraction, prolapse or stenosis
  • Skin irritation/infection
  • Uretero-ileal stricture
  • Kidney damage/deterioration of renal function
  • Lymphocele
  • Sexual dysfunction
  • Infertility
  • Need for re-operation
• Long Term Risks
  • Metabolic abnormalities related to use of bowel
  • Chronic kidney disease
  • Lifelong dependence on a stoma appliance
  • Cancer recurrence

The surgery may need conversion from robotic to open surgery, and additional procedures such as ileostomy or bilateral nephrostomy may become necessary.

6. Postoperative Course

I understand that:

• ICU care may be required
• Multiple tubes/drains and the stoma will be present
• Hospital stay: approximately 7–14 days, variable
• Recovery may take approximately 4–8 weeks
• Lifelong stoma care is required

7. Alternatives to Procedure

I have been informed of alternatives including:

• Bladder preservation with TURBT + chemotherapy + radiotherapy
• Radical cystectomy with neobladder or another urinary diversion
• Palliative chemotherapy/immunotherapy
• No treatment

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: _________________________________________