John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Patient Name:
Age:
Date:
Procedure: Cystourethroscopy, laser ablation/incision of bladder neck contracture
Indications:
Patient is a male with a history of previous prostate surgery that is complicated by a bladder neck contracture.
Alternatives:
Options include urethral dilation with clean intermittent catheterization (CIC) or chronic indwelling catheter, total destruction of bladder neck with male incontinence procedure (male sling/AUS-800), or placement of suprapubic tube via trocar or open cystotomy.
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: failure of the procedure requiring repeated same procedures or alternate options to treat, worsen of incontinence or new onset incontinence, urinary tract infection, blood in the urine, clot retention, need to use a Foley catheter for one week and perform CIC for an extended period of time to continue to mold the contracture and prevent recurrence.
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: __________________________________