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: Right/left/bilateral Orchidopexy (pediatric)

Indications:

Patients is a male with an undescended testes located in the ___________. Parent is aware that this condition is associated with a hernia that also needs to be repaired.

Alternatives:

Alternative is observation and HCG hormonal injections.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the parent(s). 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, 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 bowel or intra-abdominal structures, injury to spermatic vessels, testicle and vas deferens which may lead to loss of testicle or future infertility problems. Loss of testicle or removal of small nubbin or dysfunctional testes at the discretion of the operating surgeon. Possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal 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: __________________

Parent Signature: __________________________________ Date: __________________

Witness: __________________________________