Stage 1 Urethroplasty Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic Orchidopexy ± 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

Under general anaesthesia, the testis is mobilised through a groin/scrotal incision or laparoscopically and fixed within the scrotum.

An associated inguinal hernia is usually repaired during the same operation.

4. Benefits and Indications

The procedure may be performed when one or both testes have not descended normally into the scrotum.

The intended benefits include:

  • Placement of testis in the scrotum
  • Improved future fertility potential
  • Easier examination and surveillance
  • Reduced risk of torsion
  • Repair of associated inguinal hernia
  • Improved cosmetic appearance

Orchidopexy reduces but does not eliminate future infertility or testicular malignancy risk.

5. Risks and Complications

  • Common
    • Pain/swelling
    • Bruising
    • Mild bleeding
    • Wound discomfort
  • Less Common
    • Wound infection
    • Scrotal haematoma
    • Seroma
    • Hernia recurrence
    • Testis remaining higher than expected
    • Need for prolonged follow-up
  • Rare but Serious
    • Vas deferens injury
    • Testicular blood-vessel injury
    • Testicular atrophy
    • Re-ascent
    • Testicular torsion
    • Persistent pain
    • Anaesthetic complications
    • Orchidectomy if the testis is non-viable or severely atrophic
  • Procedure Specific
    • Diagnostic laparoscopy may be required for an impalpable testis
    • Herniotomy may be performed
    • Fowler-Stephens staged orchidopexy may be required
    • Orchidectomy may be required if the testis is severely atrophic, dysplastic or non-viable
    • A testicular remnant/nubbin may be removed if no viable testis is identified

Successful placement and preservation of the testis cannot be guaranteed. Additional surgery, staged orchidopexy or rarely orchidectomy may be required.

6. Postoperative Course

I understand that:

  • Most children are discharged the same day or within 24 hours
  • Mild pain/swelling is expected
  • Follow-up is required to assess healing and testicular position
  • Strenuous activity should be avoided for several weeks

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected situations
  • Hormonal therapy, with limited role
  • 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: _________________________________________

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic Orchidopexy ± 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

Stage 1 is intended to prepare the foundation for the new urethra and does not complete the urethral reconstruction.

The narrowed urethra is opened and marsupialised.

The patient subsequently voids through a perineal opening until Stage 2.

Stage 2 is planned at least 6 months later, when a buccal mucosal graft may be placed and tubularised to reconstruct the urethra.

4. Benefits and Indications

The procedure may be performed when one or both testes have not descended normally into the scrotum.I have been advised to undergo staged urethral reconstruction because my complex urethral stricture requires a preparatory first stage before definitive reconstruction can be performed.

The intended benefits include:

  • Establishment of a healthy, well-vascularised bed for the future graft.
  • Avoidance of a rushed single-stage reconstruction in complex disease.
  • Reduction in the risk of reconstruction failure.
  • A planned pathway toward definitive urethral reconstruction.

5. Risks and Complications

  • Common
    • Perineal or penile pain.
    • Swelling and bruising.
    • Urinary tract infection.
    • Catheter-related discomfort.
  • Less Common
    • Perineal wound infection.
    • Haematoma.
    • Wound dehiscence or breakdown.
  • Rare but Serious
    • Abandonment of the two-stage plan.
    • Conversion to permanent perineal urethrostomy.
    • Permanent suprapubic catheterisation.
    • Anaesthesia-related complications.
  • Procedure Specific
    • This is Stage 1 only.
    • The urethra is not fully reconstructed during this operation.
    • Stage 2 is planned at least 6 months later.
    • I will void through a temporary perineal opening between the two stages.
    • The graft will be placed during Stage 2.
    • Smoking should be stopped because it can impair graft healing.

6. Postoperative Course

I understand that:

  • Most children are discharged the same day or within 24 hours
  • Mild pain/swelling is expected
  • Follow-up is required to assess healing and testicular position
  • Strenuous activity should be avoided for several weeks

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Single-stage urethroplasty, if anatomy permits.
  • Permanent perineal urethrostomy.
  • Permanent suprapubic catheter.
  • 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: _________________________________________

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic Orchidopexy ± 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

Under general anaesthesia, the testis is mobilised through a groin/scrotal incision or laparoscopically and fixed within the scrotum.

An associated inguinal hernia is usually repaired during the same operation.

4. Benefits and Indications

The procedure may be performed when one or both testes have not descended normally into the scrotum.

The intended benefits include:

  • Placement of testis in the scrotum
  • Improved future fertility potential
  • Easier examination and surveillance
  • Reduced risk of torsion
  • Repair of associated inguinal hernia
  • Improved cosmetic appearance

Orchidopexy reduces but does not eliminate future infertility or testicular malignancy risk.

5. Risks and Complications

  • Common
    • Pain/swelling
    • Bruising
    • Mild bleeding
    • Wound discomfort
  • Less Common
    • Wound infection
    • Scrotal haematoma
    • Seroma
    • Hernia recurrence
    • Testis remaining higher than expected
    • Need for prolonged follow-up
  • Rare but Serious
    • Vas deferens injury
    • Testicular blood-vessel injury
    • Testicular atrophy
    • Re-ascent
    • Testicular torsion
    • Persistent pain
    • Anaesthetic complications
    • Orchidectomy if the testis is non-viable or severely atrophic
  • Procedure Specific
    • Diagnostic laparoscopy may be required for an impalpable testis
    • Herniotomy may be performed
    • Fowler-Stephens staged orchidopexy may be required
    • Orchidectomy may be required if the testis is severely atrophic, dysplastic or non-viable
    • A testicular remnant/nubbin may be removed if no viable testis is identified

Successful placement and preservation of the testis cannot be guaranteed. Additional surgery, staged orchidopexy or rarely orchidectomy may be required.

6. Postoperative Course

I understand that:

  • Most children are discharged the same day or within 24 hours
  • Mild pain/swelling is expected
  • Follow-up is required to assess healing and testicular position
  • Strenuous activity should be avoided for several weeks

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected situations
  • Hormonal therapy, with limited role
  • 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: _________________________________________

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