Patient Name:

Age:

Date:

Procedure: Excision of vesicoenteric/vesicocolonic fistula possible bowel resection and re-anastomosis

Indications:

Patient is a male/female with inflammatory bowel disease, diverticulitis, colon cancer or previous abdominal surgery that was diagnosed with a vesicle fistula to either small bowel or colon noted on CT scan/cystoscopy/barium enema/ small bowel follow through.

Alternatives:

Options include prolonged complete urinary diversion (Foley catheter, suprapubic catheter or bilateral percutaneous renal drainage) and/or complete bowel rest with total parenteral nutrition with observation.

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: bowel anastomosis leakage, peritonitis, abscess, sepsis, bowel obstruction, ileus, failure of the procedure with additional corrective surgeries may be necessary, damage to ureter requiring stent placement/removal at a later date with cystoscopy or reconstructive surgery and prolonged catheterization of the bladder,

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: __________________