John J Bauer, MD, FACS John J. Bauer, M.D.
www.flinturology.com

Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190
Email: jbauer@flinturology.com
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Counseling and Pre-Op Note

Patient Name:

Age:

Date:

Procedure: Right/left/bilateral hydroceolectomy

Indications:

Patient is a male with a non-communicating hydroceole, which is manifest by bulging in the scotum. Unless there is a testicular mass associated with this lesion there is no harm to the testicle or patient. However, if there is pain or cosmetic disfigurement secondary to the size of the hydroceole it is possible to correct this problem. If the surgery is completed to alleviate chronic pain, the patient is aware that the surgery will be successful in correcting the hydroceole but may not relieve the pain in 50% of patients.

Alternatives:

Alternative is observation, percutaneous drainage and sclerotherapy.

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: complete breakdown of the repair, prolonged wound drainage, injury to bowel or intra-abdominal structures, injury to spermatic vessels, testicle and vas deferens which may lead to loss of testicle or future infertility problems, if the testis appendix is noted it will be coagulated to prevent future torsion of the structure and persistent or worsening of the pain associated with the hydroceole may occur.

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: __________________________________