Urethral Diverticulectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urethral Diverticulectomy ± Urethral Reconstruction ± Martius Flap

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 operation is performed through the vagina.

The diverticulum is identified and completely excised, and the urethra is repaired in multiple layers.

A vascularized tissue flap such as a Martius flap may be used.

Additional urethral reconstruction or treatment for urinary incontinence may be required.

4. Benefits and Indications

The procedure may be performed for urethral diverticulum causing:

• Recurrent UTI
• Pain
• Dysuria
• Post-void dribbling
• Dyspareunia
• Palpable swelling
• Urinary incontinence
• Other urinary symptoms

The intended benefits include:

• Removal of diverticulum
• Relief of urinary symptoms
• Reduction in recurrent UTI
• Relief of pain and dyspareunia
• Improved quality of life

Complete symptom relief cannot be guaranteed.

5. Risks and Complications

• Common
  • Pain
  • Bleeding
  • UTI
  • Wound/vaginal infection
  • Bladder spasms
  • Catheter discomfort
• Less Common
  • Recurrence
  • Urethrovaginal fistula
  • SUI
  • Urethral stricture
  • Retention
  • Dyspareunia
  • Prolonged catheterization or transfusion
• Rare but Serious
  • Bladder/urethral/ureteric/bowel/vascular injury
  • Failed repair
  • Persistent incontinence
  • Thromboembolism
  • Anaesthetic complications and death, extremely rarely

6. Postoperative Course

I understand that:

• The urinary catheter usually remains for 10–21 days.
• A cystogram or VCUG may be required before removal.
• Sexual intercourse should be avoided for approximately 6–12 weeks or as advised.
• Hospital stay is usually 2–5 days.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Medical treatment for infections and symptoms
• Needle aspiration/incision in selected cases
• Continued conservative management

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: _________________________________________