VIU/DVIU Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Direct Vision Internal Urethrotomy (VIU / DVIU)

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 urethroscope is passed through the urethra under direct vision.

A cold knife, blade or laser is used to incise the scar tissue causing the narrowing and widen the urethral lumen.

No external skin incision is normally required.

A urethral catheter is generally left in place for approximately 3–5 days.

I understand that VIU is a palliative procedure and does not remove the underlying scar tissue.

The source consent states that recurrence rates may be approximately 50–80% within 12 months.

4. Benefits and Indications

The procedure may be performed for urethral stricture causing a reduced or obstructed urinary stream.

The intended benefits include:

  • Temporary improvement in urinary flow.
  • No external skin incision.
  • Relatively quick recovery.
  • Relief while planning or awaiting definitive reconstruction.
  • Best results in selected first-time short bulbar strictures.

5. Risks and Complications

  • Common
    • Haematuria.
    • Burning or discomfort during urination.
    • Urinary tract infection.
    • Stricture recurrence, approximately 50–70% within 12 months after a single VIU according to the source consent.
  • Less Common
    • Urinary retention requiring re-catheterisation.
    • False passage.
    • Inadequate widening of the urethra.
    • Progressive worsening of the stricture after repeated VIU.
    • Increasing complexity of scar tissue after multiple procedures.
  • Rare but Serious
    • Urethral perforation and extravasation.
    • Urosepsis.
    • Erectile dysfunction.
    • Urinary incontinence.
  • Procedure Specific
    • VIU is palliative rather than curative.
    • Recurrence is expected in a significant proportion of patients.
    • Repeated VIU may make subsequent urethroplasty more difficult.
    • Urethral self-calibration/self-dilatation may be advised.
    • Definitive urethroplasty may be recommended if VIU fails.
    • The catheter generally remains for 3–5 days.

6. Postoperative Course

I understand that:

  • Day-care or overnight hospitalisation.
  • Catheter removal after approximately 3–5 days.
  • Return to normal activities in approximately 5–7 days.
  • Follow-up uroflowmetry at approximately 3–6 months.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Urethral dilatation.
  • BMG urethroplasty.
  • IPG urethroplasty.
  • Flap urethroplasty.
  • End-to-end anastomotic urethroplasty for suitable strictures.
  • Perineal urethrostomy for complex recurrent disease.
  • Permanent suprapubic catheterisation in selected patients.

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