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: Cystoscopy Under Anesthesia (CUA) or Office cystoscopy with periurethral injection of bulking agents

Indications:

Patient is a male / female with a history of urinary incontinence (stress or mixed). Male patients with stress urinary incontinence secondary to previous prostate surgery for benign and malignant conditions or has an incompetent sphincter secondary to neurological disease are indicated for this procedure. Urodynamic studies have confirmed the presence of Type III stress urinary incontinence or mixed incontinence with a low valsalva leak point pressure.

Alternatives:

Alternatives include watchful waiting, Kegel exercises, behavioral/biofeedback/electrical stimulation therapy, penile clamp/condom catheter/male sling for males, urethral plugs/pubovaginal sling for females and an artificial urinary sphincter (AUS-800).

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: urinary tract infection, blood in the urine, clot retention, urinary retention, possible need for short term clean intermittent catheterization (CIC), multiple injects may be necessary to obtain an improvement. Results suggest that 25% of males with mild incontinence will be dry after an average of 5 injections, 88% will be improved, females with pure type III SUI have greater than 85% chance of being dry after multiple injections, females with Type I and II hypermobility incontinence have nearly a 50% dry rate.

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: __________________________________