TURBT Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Trans-Uretheral Resection of Bladder Tumor

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

TURBT is an endoscopic procedure performed through the urethra using a resectoscope.

An electrical loop or laser is used to cut and remove the tumor from the bladder wall.

The removed tissue is sent for pathological examination.

A single dose of intravesical chemotherapy, such as Mitomycin-C or Gemcitabine, may be given immediately following the procedure where appropriate.

4. Benefits and Indications

The procedure may be performed for:

• Bladder tumor
• Hematuria

TURBT is both a diagnostic and therapeutic procedure.

The primary goal is removal of visible tumor tissue and obtaining tissue for pathological diagnosis.

The final treatment plan, including the need for further surgery, BCG therapy or chemotherapy, depends on the pathology report.

5. Risks and Complications

• Bladder perforation (1–5%)
• Obturator nerve reflex
• Bleeding
• Hematuria and clot retention
• UTI
• Frequency and urgency
• Urethral stricture (2–3%)
• Tumor recurrence (50–70%)
• Vesicoureteral reflux

6. Postoperative Course

I understand that:

• Day-care surgery or overnight admission may be required.
• A urinary catheter may remain for 1–3 days to allow bladder healing and irrigation.
• Blood or clots may occur in the urine following surgery.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Observation/cystoscopic surveillance in selected cases
• Radical cystectomy
• Radiation/chemotherapy

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: _________________________________________