Retrograde Intrarenal Surgery Consent

Informed Consent For Surgical Operation / Procedure

Procedure: RIRS With Laser Lithotripsy

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

IRS is a scarless endoscopic procedure performed through the natural urinary passage.

A flexible scope is passed through the bladder and ureter into the kidney.

A Holmium:YAG laser is used to dust or fragment the stone.

A DJ stent is almost always placed at the end of the procedure.

4. Benefits and Indications

The procedure may be performed for:

  • Renal calculus/kidney stone
  • Ureteric calculus

RIRS is described in the consent as highly effective for stones up to 1.5–2 cm.

The stone may be dusted into fine fragments that pass in the urine.

A DJ stent generally remains temporarily and usually requires a subsequent cystoscopic procedure for removal after 1–3 weeks.

5. Risks and Complications

  • Ureteral injury (<1%)
  • Access failure (5%)
  • Bleeding
  • Stent symptoms (60–80%)
  • UTI/Sepsis (3–7%)
  • Ureteric colic
  • Ureteric stricture (1%)
  • Residual fragments

6. Postoperative Course

I understand that:

  • Day-care surgery or overnight admission may be required.
  • The DJ stent may remain for 1–3 weeks and requires subsequent removal.
  • Fine stone fragments may pass in the urine for several days following surgery.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Manual aspiration
  • Continuous bladder irrigation (CBI)
  • Open cystotomy where endoscopic evacuation fails

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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