REZUM Consent

Informed Consent For Surgical Operation / Procedure

Procedure: REZUM Water Vapor Therapy

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

Rezum is a minimally invasive endoscopic procedure performed through the urethra.

A specialized device injects sterile water vapor into obstructing prostate tissue. The resulting thermal energy causes the treated tissue to die and subsequently be reabsorbed by the body.

A temporary urinary catheter or stent is usually required for 3–7 days because of initial prostate swelling.

4. Benefits and Indications

The procedure may be performed for:

• Benign Prostatic Hyperplasia (BPH) Bladder Outlet Obstruction

The intended benefit is improvement in urinary flow and symptoms while preserving sexual function.

I understand that:

• The full benefit occurs as the treated tissue is reabsorbed.
• Symptoms may temporarily worsen during the first 1–2 weeks.
• Significant improvement is typically noticed between 2 weeks and 3 months.

5. Risks and Complications

• Urinary retention (up to 10–15%)
• Dysuria
• Hematuria/hematospermia
• Frequency and urgency
• UTI
• Retrograde ejaculation (3–5%)
• Treatment failure/recurrence
• Erectile dysfunction risk considered extremely low

6. Postoperative Course

I understand that:

• Day-care surgery or overnight admission may be required.
• A catheter or stent is usually required for 3–7 days.
• Urinary symptoms may initially worsen because of inflammatory swelling and gradually improve over the following weeks.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Medical management
• TURP
• HoLEP/ThuLEP
• UroLift
• Prostate Artery Embolization
• Observation

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: _________________________________________