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: Extracorporeal Shock Wave Lithotripsy (ESWL) of the Ureter

Indications:

Patient has been diagnosed with a symptomatic stone in the urinary tract system.

Alternatives:

Alternative include: watchful waiting with pain medication for symptoms, ureterorenoscopy with stone extraction/EHL/laser/Lithoclast, percutaneous lithotomy with stone extraction/EHL/laser/Lithoclast/ultrasonic lithotripsy or open surgical removal. Some stones may be slowly dissolved over time with medication; however, this is only recommended for the asymptomatic stone.

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: If stone burden is large you may require a cystoscopy and stent placement to avoid post procedure �steinstrasse� accompanied with obstruction and urosepsis, if stent placement is required there are complications of this procedure such as: injury to bladder; ureter or kidney that may require percutaneous renal drainage; ureteral and renal reconstructive surgery or removal of the kidney ,flank pain and/or bruising, hematuria (micro or gross), renal hematoma and bleeding, high blood pressure in the future, failure of the procedure and possible repeat ESWL or more invasive alternative procedures may be necessary to get complete stone removal.

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: __________________________________