Radical Orchidectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Radical Orchidectomy

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 entire testis and spermatic cord are removed through an inguinal incision.

The specimen is sent for histopathological examination.

A testicular prosthesis may be offered where applicable.

4. Benefits and Indications

The procedure may be performed for a suspected or confirmed testicular cancer.

The intended benefits include:

  • Removal of suspected/confirmed cancer
  • Accurate diagnosis and staging
  • Prevention of disease progression

Further chemotherapy, radiotherapy or surgery may be required depending on the final histopathology and staging.

5. Risks and Complications

  • General Risks
    • Bleeding: approximately 1–5%
    • Infection: approximately 1–5%
    • Pain
    • Haematoma
    • Anaesthetic complications
  • Procedure-specific Risks
    • Scrotal haematoma/swelling: 5–10%
    • Wound infection/delayed healing: 2–5%
    • Injury to surrounding structures
    • Chronic groin pain/numbness: 5–10%
    • Cosmetic concerns/asymmetry
  • Functional and Psychosocial Risks
    • Infertility, particularly when the opposite testis is abnormal or previous treatment has affected fertility
    • Reduced testosterone levels
    • Possible hormone replacement
    • Psychological/body-image concerns

6. Postoperative Course

I understand that:

  • Usually same-day discharge or 1–2 days hospital stay
  • Mild pain and swelling are expected
  • Scrotal support is advised
  • Normal activity may resume in approximately 2–4 weeks
  • Follow-up is essential for staging and further treatment

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation, although not recommended for suspected malignancy
  • Testis-sparing surgery in highly selected cases
  • Biopsy, which is generally avoided because of tumour-spread concerns

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: _________________________________________

Related Posts