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 nephrolithotomy (PNL)

Indications:

Patient has been diagnosed with a large stone in the upper collecting system causing symptoms of pain/hematuria/infection/loss of renal function/obstruction.

Alternatives:

Alternatives include observation, multiple ESWL, ureteroscopy, and open surgical procedures. Observation is not recommended due to increased likelihood of renal damage, ESWL and ureteroscopy is not recommended since there is a likelihood of multiple procedure and decreased success rate, open surgery is not the first choice due to the invasiveness of the procedure and prolonged recuperation time, however, has an equal to better success rate than the PNL.

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: pleural effusion and potential need for chest tube drainage, access tract and renal bleeding, need for placement of a percutaneous drainage tube or urteral stent to avoid obstruction, urinary tract infection, sepsis, hematoma formation, urinoma, fistula, damage to kidney, renal pelvis or ureter requiring further procedures for reconstruction or removal of kidney, injury to the urethra/bladder and ureter during cystoscopy for placement of the wires and ureteral occlusion balloon, failure to remove all stone fragments leading to: need for ESWL sandwich therapy; second look PNL procedure; ureteroscopy; or open exploration, prolonged percutaneous drainage until all stone removed with additional procedures, damage to adjacent organs (bowel, spleen, liver, lung), chronic flank or abdominal pain, failure to relieve existing pain and recurrence of stone disease.

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: __________________________________