Patient Name:

Age:

Date:

Procedure: Partial Nephrectomy

Indications:

Patient was found to have a mass of the kidney (benign or malignant) with CT characteristics suggesting malignancy. The tumor is in an anatomical location that permits renal sparring surgery. Size criteria, clinical staging, and metastatic work-up (blood work, CT Abdomen, bone scan and CXR) are supportive of this procedure. This procedure is being performed for cure, yet to spare as much renal parenchyma as possible to prevent the development of chronic renal insufficiency in the future.

Alternatives:

Alternatives include laparoscopic procedure in an experienced surgeons hands, observation with serial CT scans, removal of the entire kidney.

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: possible need to remove the entire kidney with possible future dialysis and or transplantation required, late hemorrhage, urinary fistula, possible need to place ureteral stent or percutaneous drainage to correct the fistula, chronic hypertension, recurrence of the tumor in the future, failure of the procedure requiring adjuvant immunotherapy, renal obstruction, and a 10% chance of developing a renal tumor in remaining kidney, positive surgical margins requiring further surgery to remove more tissue or entire kidney, pleural effusion, pneumothorax requiring chest tube placement post-operatively and partial loss of a rib.

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: __________________