Patient Name:

Age:

Date:

Procedure: Right/left/bilateral Epididymectomy

Indications:

Patient is a male with a history of chronic pain localized to the epididymis. There have been multiple forms of treatment to alleviate the pain, all of which have failed. If the surgery is completed to alleviate chronic pain, the patient is aware that the surgery may be successful in correcting the pain syndrome, but may not relieve the pain in 50% of patients.

Alternatives:

Alternative is observation, pain medications, sitz baths, anesthesia pain regimen, repeated spermatic cord blocks and surgical removal.

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 spermatic vessels, testicle, testicular blood supply and vas deferential artery 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 area where the epididymis was anatomically removed may occur. The connection between the testes and the vas deferens will be severed and no sperm can proceed to the semen from the side of surgery.

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: __________________