Vesicovaginal Fistula Repair Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Vesicovaginal Fistula Repair

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 fistulous tract is identified and excised as required.

The bladder and vaginal walls are repaired separately.

A tissue interposition flap, such as Martius or omental flap, may be used.

Ureteric stents or ureteric reimplantation may be required if the fistula is close to the ureteric openings.

An additional suprapubic catheter may be placed for complex or large fistulas.

4. Benefits and Indications

The procedure may be performed to repair an abnormal communication between the bladder and vagina causing continuous urinary leakage.

The intended benefits include:

  • Closure of the fistula
  • Restoration of urinary continence
  • Prevention of recurrent infections
  • Improved quality of life

Complete success cannot be guaranteed, and repeat surgery may occasionally be necessary.

5. Risks and Complications

  • Common
    • Pain
    • Bleeding
    • Wound/Vaginal Infection
    • Urinary tract infection
    • Bladder Spasms
    • Catheter Discomfort
  • Less Common
    • Prolonged urinary leakage
    • Fistula recurrence
    • Urinary incontinence
    • Voiding difficulty
    • Ureteric injury
    • Need for transfusion
  • Rare but Serious
    • Bowel/ureteric/vascular injury
    • Need for urinary diversion
    • Thromboembolism
    • Anaesthetic complications
    • Reoperation and death, extremely rarely

6. Postoperative Course

I understand that:

  • The urinary catheter usually remains for 10–21 days.
  • Sexual intercourse should be avoided for approximately 3 months or as advised.
  • Hospital stay is usually 3–7 days.
  • Temporary bladder spasms, mild haematuria and catheter care are expected. Regular follow-up is necessary.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Prolonged catheter drainage for selected small fresh fistulas
  • Urinary diversion in selected complex cases
  • Conservative management 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: _________________________________________

Related Posts