Robotic Partial Nephrectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Robotic Partial Nephrectomy

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 tumour or diseased part of the kidney is removed while preserving the remaining healthy kidney tissue using a robot-assisted laparoscopic approach.

4. Benefits and Indications

The procedure may be performed forselected renal tumours or suspicious renal lesions where preservation of functioning kidney tissue is considered appropriate.

The intended benefits include:

  • Removal of kidney tumour/suspicious lesion
  • Preservation of kidney tissue and kidney function
  • Potential oncological control
  • Minimally invasive approach
  • Potentially faster recovery and less pain

5. Risks and Complications

  • Intra Operative
    • Bleeding: 5–15%
    • Blood transfusion: 2–10%
    • Major vascular injury: 1–5%
    • Injury to bowel, liver, spleen, pancreas, pleura, ureter or diaphragm: 1–5%
    • Renal vessel clamping/warm ischaemia affecting kidney function
    • Prolonged surgery due to adhesions, obesity or tumour location
    • Conversion to open surgery: 2–10%
    • Conversion to radical nephrectomy: 2–10%
    • Collecting-system entry requiring repair/stenting
    • Anaesthetic complications: <1–2%
    • DVT/PE: 1–2%
    • ICU care: 1–5%
    • Rare death: <1%
  • Post Operative
    • Port-site pain Wound infection: 2–5%
    • Bleeding/haematoma: 2–10%
    • Urinary leak/fistula: 2–10%
    • Need for ureteral stent/drain/additional intervention: 2–10%
    • Pseudoaneurysm/delayed bleeding: 1–5%
    • Reduced kidney function/acute kidney injury: 2–10%
    • Dialysis: rare, <1–2%
    • Positive surgical margin/residual tumour: 1–10%
    • Tumour recurrence Ileus: 2–5%
    • Chest complications: 1–5%
    • Port-site/incisional hernia: 1–3%
    • Readmission/reoperation: 2–10%

The robotic procedure may be converted to open surgery.

If partial nephrectomy is technically unsafe or not feasible, radical nephrectomy may be required for safety or cancer control.

6. Postoperative Course

I understand that:

  • The final diagnosis and treatment plan depend on histopathology.
  • A urinary catheter, drain and occasionally a DJ stent may be required.
  • Further management may depend on:
    • Histopathology
    • Surgical margins
    • Kidney function
    • Recurrence risk
  • Further surgery, embolisation, stenting or oncological treatment may occasionally be required. Close follow-up with blood tests, imaging and medical review is necessary.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Active surveillance for selected small renal masses
  • Radiofrequency ablation/cryoablation
  • Open partial nephrectomy
  • Radical nephrectomy
  • Conservative treatment where appropriate

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