John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Patient Name:
Age:
Date:
Procedure: Extracorporeal Shock Wave Lithotripsy (ESWL)
Indications:
Patient has been diagnosed with a symptomatic stone in the urinary tract system.
Alternatives:
Alternative include: watchful waiting with pain medication for symptoms, ureterorenoscopy with stone extraction/EHL/laser/Lithoclast, percutaneous lithotomy with stone extraction/EHL/laser/Lithoclast/ultrasonic lithotripsy or open surgical removal. Some stones may be slowly dissolved over time with medication; however, this is only recommended for the asymptomatic stone.
Risks/Complications:
The risks and complications of the procedure where extensively discussed with the
patient. The general risks of this procedure include, but are not limited to bleeding,
transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the
procedure, potential injury to other surrounding structures, deep venous thrombosis,
pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term
stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious
complications of the anesthesia to include cracked teeth, airway damage, aspiration,
pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant
hyperthermia. Your anesthesiologist will discuss the risks and complications in more
depth separately. Additional procedures may be necessary.
Physician's Signature: ________________________________ Date: __________________
Patient Signature: __________________________________ Date: __________________
Witness: __________________________________