Urethrovaginal Fistula Repair Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urethrovaginal Fistula Repair ± Martius Flap ± Urethral Reconstruction

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 fistula is identified and repaired by separating the urethra from the vagina and closing both layers separately.

A vascularized tissue flap such as a Martius flap may be used to reinforce the repair.

Additional urethral reconstruction or anti-incontinence procedures may be required.

4. Benefits and Indications

The procedure may be performed for an abnormal communication between the urethra and vagina causing:

  • Continuous urinary leakage
  • Recurrent UTI
  • Pain
  • Difficulty with urinary control

The intended benefits include:

  • Closure of the fistula
  • Resolution or significant reduction in urinary leakage
  • Preservation/improvement of urethral function
  • Reduction in recurrent infections
  • Improved quality of life

Complete continence or successful closure cannot be guaranteed.

5. Risks and Complications

  • Common
    • Pain
    • Bleeding
    • Infection
    • Urinary tract infection
    • Bladder Spasms
    • Catheter Discomfort
  • Less Common
    • Recurrent fistula
    • SUI
    • Urethral stricture
    • Voiding difficulty
    • Dyspareunia
    • Prolonged catheterization or transfusion
  • Rare but Serious
    • Bowel, ureteric or vascular injury
    • Failed repair
    • Urethral loss
    • Thromboembolism
    • Anaesthetic complications and death, extremely rarely

6. Postoperative Course

I understand that:

  • The catheter usually remains for 2–3 weeks.
  • A dye test or cystourethrogram may be required before catheter removal.
  • Sexual intercourse should be avoided for approximately 3 months or as advised.
  • Hospital stay is usually 2–5 days.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Prolonged catheter drainage in selected fresh fistulas
  • Conservative management
  • Urinary diversion in selected complex cases

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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