UROLIFT Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Prostati Urethral Lift

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

UroLift is a minimally invasive procedure performed through the urethra.

Small permanent metal and suture implants are placed to pull back obstructing prostate tissue and widen the urinary channel.

No prostate tissue is removed, heated or destroyed.

Most patients do not require a urinary catheter, although one may be placed for 24 hours if necessary.

4. Benefits and Indications

The procedure may be performed for:

  • Benign Prostatic Hyperplasia (BPH)
  • Bladder Outlet Obstruction

The primary goal is to:

  • Improve urinary flow
  • Preserve sexual function
  • Preserve ejaculatory function
  • Provide relatively rapid symptom relief

Symptoms may improve within approximately 2 weeks.

5. Risks and Complications

  • Dysuria (25–30%)
  • Hematuria
  • Frequency/urgency
  • Pelvic pain
  • Urinary retention
  • Implant encrustation
  • Treatment failure (approximately 13% over 5 years)
  • UTI/prostatitis

6. Postoperative Course

I understand that:

  • Day-care surgery or overnight admission may be required.
  • Most patients do not require a catheter.
  • If required, catheterization may continue for approximately 24 hours.
  • Mild burning, hematuria, frequency, urgency and pelvic discomfort may occur during the healing period.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Medical management
  • TURP
  • HoLEP
  • ThuLEP
  • Rezum
  • Observation

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: _________________________________________

Related Posts