Urethral Dilatation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urethral Dilatation Consent

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

Progressively larger urethral sounds, bougies or balloon dilators are passed through the urethra to stretch and widen the narrowed segment.

The procedure may be performed under:

  • Local anaesthetic gel.
  • Regional anaesthesia.
  • General anaesthesia.

A catheter may be left in place for approximately 3-5 days.

I understand that urethral dilatation is a palliative procedure.

It stretches the scar but does not remove the underlying scar tissue.

The source consent states recurrence rates of approximately 60–80% within 12 months.

4. Benefits and Indications

The procedure may be performed urethral stricture causing a poor or obstructed urinary stream.

The intended benefits include:

  • Temporary improvement in urinary flow.
  • Quick procedure with minimal recovery.
  • Avoidance of immediate open surgery in selected patients.
  • An option for patients who are unfit for open reconstruction.

5. Risks and Complications

  • Common
    • Haematuria.
    • Burning or discomfort during urination.
    • Urinary tract infection.
    • Stricture recurrence, approximately 60–80% within 12 months according to the source consent.
  • Less Common
    • Urinary retention requiring re-catheterisation.
    • False passage.
    • Increasingly dense scar formation with repeated dilatation.
    • Increasing difficulty with future urethroplasty.
    • Significant procedural pain/discomfort.
  • Procedure Specific
    • I understand that repeated dilatation may result in additional scar formation and may make subsequent definitive urethroplasty more technically difficult.
    • I understand that this procedure provides temporary symptomatic relief rather than definitive treatment.

6. Postoperative Course

I understand that:

  • A catheter may remain for approximately 3–5 days.
  • Mild haematuria and burning during urination may occur for several days.
  • Urinary flow should be monitored.
  • Recurrence may require repeat treatment or definitive urethroplasty.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • VIU/DVIU.
  • Definitive BMG/IPG/flap urethroplasty.
  • Urethral self-dilatation.
  • Permanent suprapubic catheterisation in selected patients.

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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