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: Percutaneous direct vision laser endopyelotomy

Indications:

Patient is a male/female with documented ureteropelvic junction obstruction on lasix renal scan.

Alternatives:

Options include Accucise endopyelotomy, ureteroscopic direct vision endopyelotomy, percutaneous direct vision endopyelotomy, open pyeloplasty, lower pole urterocalycostomy and chronic ureteral stent with period exchange via cystoscopy.

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: failure of the procedure, obstruction, stone formation, pyelonephritis, pyonephrosis, persistent flank pain, injury to vascular structures, gonadal artery damage with possible atrophy or loss of ovary or testicle, prolonged urteral stent placement and possible percutaneous renal drainage, tract bleeding, renal hematoma, bowel injury that may require open surgery and fecal stream diversion with external appliance for 3 months then re-connection of the bowel segments, pneumothorax, and damage to lung with possible chest tube placement.

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: __________________________________