Patient Name:

Age:

Date:

Procedure: Cystolithalopaxy

Indications:

Patient is a male/female diagnosed with bladder calculi symptomatic with microscopic/gross hematuria, irrative voiding symptoms, urinary tract infections or obstruction.

Alternatives:

Alternatives to this procedure are observation with antibiotics, ESWL, and 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: incomplete removal of stones, repeat procedure, possible additional ESWL or open cystotomy, persistent urgency after procedure, urinary tract infection, sepsis, possible damage to urethra and bladder from EHL probe, laser energy, Lithoclast and the lithotrite, if the bladder is perforated their may be damage to the intestines and further procedures will be required for repair potentially including a bowel diversion procedure with ostomy appliance and repair of bladder injury, may require prolonged indwelling catheterization to drain bladder and may be required to do biopsies of suspicious lesions or resection of tumor that is found incidentally.

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: __________________