Patient Name:

Age:

Date:

Procedure: Spermatic Cord Lysis (Skeletonization)

Indications:

Patient is a male diagnosed with symptomatic testicular or epididymal pain. This pain has been chronic and unremitting in character. All conservative therapies have been attempted without success.

Alternatives:

Options include but are not limited to: observation, oral analgesics, repeat trial of long-term antibiotics, repeated cord blocks, TENS therapy (nerve stimulation therapy), epididymectomy and orchiectomy.

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: complete breakdown of the repair, prolonged wound drainage, injury to spermatic vessels, testicle and vas deferens which may lead to loss of testicle or future infertility problems. Possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal skin. This could also lead to separate chronic pain syndrome. It was repeatedly reinforced that this is a last radical effort to control the chronic pain that the patient is experiencing. He was made aware of the fact that this procedure may fail and that the pain may continue even after the spermatic cord has been skeletonized of all muscle and nerve tissue. Significant risk to the viability of the testicle is a potential outcome of this surgery.

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: __________________