Patient Name:

Age:

Date:

Procedure: Cystoscopy under anesthesia (CUA), possible stone extraction, bladder biopsies or tumor resection, urteral stent placement, retrograde pyelograms

Indications:

Patient is a male/female with a history of irrative bladder symptoms or blood in the urine. The patient may also have stone disease and require placement of a ureteral stent or stone extraction, have an incidental bladder tumor or abnormal voided cytologies that require systematic biopsy or resection of tumor. Patient may have an incomplete IVP study that requires better anatomical delineation of upper collecting system anatomy by injecting dye under direct vision.

Alternatives:

No other options exist that are prudent courses of action. If patient adamantly refuses the procedure a potential option is observation with repeat voided cytologies and continuous urine analysis monitoring. Patient needs to be aware that a potential lethal bladder condition may be missed without CUA. Stent placement can be replaced with percutaneous drainage of the kidney, stone extraction could be accomplished with ureteroscopy and stone extraction/destruction or ESWL treatment.

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, sepsis, worsening blood in the urine, clot retention, injury to urethra/bladder/ureter requiring additional procedures to repair.

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: __________________