Patient Name:

Age:

Date:

Procedure: Open prostatectomy, possible diverticulectomy or bladder stone removal

Indications:

Patient is a male with lower urinary tract irrative or obstructive voiding symptoms that has not responded adequately to medical therapy. The size of the prostate on transrectal ultrasound is of sufficient weight that would potentially require a stage TURP or have a higher likelihood of complications if a trans-urethral procedure was completed. If patient has an incidental diverticulum or bladder stones these entities will be dealt with during the open prostatectomy.

Alternatives:

Alternatives are watchful waiting, continued oral medical therapy in combination with finasteride, transurethral resection of the prostate (TURP), staged TURP, chronic indwelling catheter or suprapubic catheter drainage, laser therapy, microwave therapy, ultrasound therapy and thermotherapy.

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: impotence, incontinence, retrograde ejaculation, bladder neck contracture, life-threatening bleeding requiring invasive vascular occlusion techniques, urinary tract infection, prolonged Foley catheter drainage or suprapubic tube placement, prolonged gross hematuria, may find prostate cancer on the pathology specimens and require further surgery, radiation or hormonal therapy for this entity, damage to bladder, sphincter muscle, ureters and additional procedures to correct these complications. You may require resection of a diverticulum or removal of bladder stones if found incidentally during the procedure.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________