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: Nesbitt Tucks possible plaque excision

Indications:

Patient is a male with a penile curvature or Peyronnies disease that causes painful erections or painful intercourse. The process has been stable for a minimum of 6-months.

Alternatives:

Options include observation, continued use of oral medical therapy (Vitamin E, POTABA), radiation to alleviate pain, steroid or calcium channel blocker injection therapy, reconstructive penile surgery or a penile prosthesis

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: penis may still have a slight curvature after the surgery, operation may fail anytime after the surgery, penile shortening, nerve damage, impotence, orgasm change, numb areas on the penis, may require penile prosthetic at a latter date for failures, penile bruising and small lumps where sutures are placed that can be felt under the skin.

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: __________________________________