John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Patient Name:
Age:
Date:
Procedure: Augmentation Cystoplasty with bowel
Indications:
Patient is a male/female with severe bladder dysfunction. Patient has undergone thorough evaluation with urodynamic testing (UDT�s) demonstrating a small capacity bladder intractable hyperreflexia or detrussor instability with or without urge incontinence without response to typical medical therapy. Patient was given the options and has chosen an augmentation cystoplasty.
Alternatives:
Alternatives include: watchful waiting, timed voiding, continued medical therapy, Interstim therapy, behavioral/biofeedback/pelvic floor electrical stimulation therapy, and condom catheter.
Risks/Complications:
ThThe 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 to improve urinary urgency and incontinence, bowel/bladder/ureteral injury, persistent pelvic serous drainage, urinary stones, urinary tract infections/pyelonephritis, hernias, metabolic abnormalities that may need chronic medication, adhesions, ileus, fecal fistula, and atelectasis
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: __________________________________