Patient Name:

Age:

Date:

Procedure: Excision of vesicovaginal/urethrovagnal/ureterovaginal fistula, possible ureteral reimplant

Indications:

Patient is a female with a symptomatic urethral or vesicovaginal fistula.

Alternatives:

Options include observation with prophylactic antibiotic usage, prolonged Foley catheterization, prolonged suprapubic catheterization or prolonged bilateral percutaneous renal drainage. Prolonged ureteral stent placement is an option for ureterovaginal fistula. Options for surgery are vaginal approach or abdominal approach.

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: prolonged urethral catheterization, urethral diverticulum, urethral abscess, stricture formation, future alternative procedures for failures, prolonged dysuria and injury to rectum/bladder/ureters. If vaginal approach is unsuccessful then it may be converted to an open abdominal surgery. If this procedure is a redo or a very large fistula an interposition with labial fat pad or omentum will be required. If there is a ureterovaginal fistula a distal ureterectomy and re-implant may be required. Ureteral stent placement will be needed with removal by cystoscopy at a later date.

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: __________________