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: Penile Prosthesis (3-piece, AMS-700CX)

Indications:

Patient is a male who is scheduled to have placement of a penile prosthesis. This operation is most often performed for severe erectile dysfunction and allows a patient to have an erection, which is usable for sexual intercourse.

Alternatives:

Alternatives to the procedure include observation; oral agents such as sildenafil, trazadone, and yohimbine; pharmacological injection programs (alprostadil, papaverine, phentolamine and combinations); vacuum tumescence devices; intra-urethral therapy (alprostadil); and behavioral/sexual therapy. Several types of penile implants are available: malleable, semi-rigid; self contained inflatable; and multi-piece inflatable with connectors.

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(short and long term), 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: prosthetic infection requiring long term treatment with antibiotics, penile/urethral injury, removal of prosthetic secondary to erosion or infection, inability to place a specific type of prosthetic (inflatable vs. semi-rigid) requiring the placement of an alternative type, prosthesis failure/breakage/leakage requiring future revision/removal/ replacement, altered cosmetic appearance, perforation of the cura, crossed rods, delayed climax and spontaneous erections. With a prosthetic device you will be required to take prophylactic antibiotics before any other surgical or dental procedures to prevent possible bacterial seeding and infection of you prosthetic. The glans penis may droop (SST deformity) after surgery or after some use of the prosthesis during intercourse.

It is also vitally important to have realistic expectations of the surgery. The penile prosthesis does not give the same type ´┐Żnormal´┐Ż erection, but acts as a device to increase the penile rigidity for intercourse. You may be dissatisfied with the appearance and size of the penis after the surgery. This procedure will not give you increased length and girth.

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: __________________________________