John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
|
Patient Name:
Age:
Date:
Procedure: Transurethral resection of the ejaculatory ducts
Indications:
Patient is a male with infertility with one or more of the following: low sperm count, abnormal morphology of sperm, decreased motility, decreased semen volume, palpable ejaculatory duct cyst, seminal vesicle cyst or demonstration of the cysts on transrectal ultrasound.
Alternatives:
Alternatives to the procedure is artificial reproductive techniques, aspiration of sperm from epididymis or testis, testis biopsy for harvest of sperm.
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.
The specific risks of this procedure include, but are not limited to: injury to or perforation of prostate capsule or bladder, ureteral injury or obstruction, additional procedures to correct injury (stent, percutaneous renal drainage), urinary tract infection, pyelonephritis, irrative voiding symptoms, incontinence, gross hematuria, clot retention, may require prolonged catheterization or recatheterization, retrograde ejaculation, inability to void due to bladder dysfunction, and erectile dysfunction. May require an incision of the urethra using an Otis urethrotome if the urethra can not be dilated to fit the scope, this may cause prolonged bleeding, penile pain and catheterization
You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.
Physician's Signature: ________________________________ Date: __________________
Patient Signature: __________________________________ Date: __________________
Witness: __________________________________