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: Radical nephroureterectomy

Indications:

Patient was found to have a mass of the renal pelvis or the middle/proximal ureter (benign or malignant) with CT characteristics suggesting malignancy. Metastatic work-up (blood work, CT Abdomen, bone scan and CXR) is supportive of this procedure. This procedure is being performed for cure, and may cause chronic renal insufficiency in the future requiring dialysis or transplantation.

Alternatives:

Alternatives include laparoscopic procedure in experienced surgeons hands, ureterorenoscopy with laser ablation of tumor, prolonged ureteral instillation of immunotherapy drugs (BCG, Interferon), percutaneous surgery.

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: chronic hypertension, recurrence of the tumor in the future, possible new bladder tumor formation, failure of the procedure requiring adjuvant radiation and/or chemotherapy, damage to surround organs and their sequellae (lung, liver, spleen, colon, small bowel, great vessels, pancreas, gondal artery injury leading to loss of ovary or testicle), pleural effusion, pneumothorax requiring chest tube placement post-operatively, may have to do extensive vascular surgical procedures if there is a renal vein, vena caval, hepatic vein thrombosis, if the thrombus extends into the right heart then a by-pass procedure and additional chest incision will be required to attempt removal of all the tumor, partial loss of a rib. Patient is aware that he will require two incisions, one flank incision to remove the kidney pelvis and proximal ureter and one in the lower abdomen to remove the distal ureter and bladder cuff.

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: __________________________________