Urinary Diversion Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urinary Diversion

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

A segment of intestine is used to divert urine.

Depending on the reconstruction:

• A neobladder may be connected to the urethra
• Urine may drain through a stoma into an external bag
• A continent reservoir may be emptied by catheterization

4. Benefits and Indications

The procedure may be performed when the bladder or lower urinary tract is unable to safely store or empty urine because of disease or injury.

The objectives are safe urinary drainage, preservation of kidney function and improved quality of life.

The intended benefits include:

• Good urinary drainage
• Protection of kidney function
• Relief of symptoms
• Improved quality of life

5. Risks and Complications

• Common
  • Pain
  • Ileus
  • UTI
  • Wound infection
  • Minor bleeding
  • Mucus secretion
• Less Common
  • Transfusion
  • Bowel obstruction
  • Urinary leak
  • Wound dehiscence
  • Stoma complications
  • Uretero-enteric stricture
  • Metabolic acidosis
  • Vitamin B12 deficiency
  • Pouch stones and pouchitis
• Rare but Serious
  • Bowel, ureteric or vascular injury
  • Sepsis
  • Peritonitis
  • Renal Failure
  • Anaesthetic complications
  • DVT/PE
  • Revision Surgery

6. Postoperative Course

I understand that:

• Hospital stay is usually 7–14 days.
• Temporary drains, stents and catheters may be required.
• Stoma/catheterization education and long-term follow-up are essential. Lifelong stoma care or catheterization may be required.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Conservative management
• Long-term catheter
• Suprapubic catheter
• CIC
• Other reconstructive procedures
• No treatment where appropriate

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: _________________________________________