Patient Name:

Age:

Date:

Procedure: Open cystotomy for suprapubic cystotomy tube placement or stone removal

Indications:

Patient is a male / female with a history of neurogenic bladder/atonic bladder/prostatic obstruction that requires extended urinary drainage or has a large bladder stone that requires open procedure fro removal.

Alternatives:

Options include observation, chronic indwelling Foley catheter or trocar cystotomy with cystoscopy guided suprapubic tube placement. Stone removal can be done alternatively using endoscopic procedures or ESWL.

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: urinary tract infection, blood in the urine, injury to the bladder/intestines/rectum and ureters. Bowel injury once diagnosed may require further surgical procedures to correct the bowel injury possibly including a bowel diversion and external appliance for an extended period of time. Reconnection of the bowel segments will then be required at a later date. If ureters are injured possible reconstruction or stent placement may be required with cystoscopy removal at a later date.

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: __________________