Patient Name:

Age:

Date:

Procedure: Ureteral re-implant, possible distal ureterectomy

Indications:

Patient presents with a history of previous surgery, distal ureteral stricture, ureteral cancer or congential narrowing of the distal ureter and requires a distal ureterectomy with ureteral re-implant.

Alternatives:

Options include watchful waiting, placement of a chronic ureteral stent with exchanges at regular intervals, percutaneous renal drainage, primary ureteroureterotomy, and trans ureteroureterotomy.

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 headache, 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 bowel, ureter or pelvic vascular structures, ileus, bowel obstruction, recurrent tumor formation, urinary tract infection, wound scarring, prolonged ureteral stent placement and cystoscopy at later date to remove stent and irrative bladder symptoms. May require a renal mobilization and nephropexy, psoas hitch, Boari flap construction to allow re-implant.

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: __________________