John J. Bauer, M.D.
Procedure: Radical cystectomy with orthotopic neobladder
Patient presents with a high grade, invasive bladder cancer diagnosed by TURBT. Metastatic work-up of liver function tests, CT scan of the pelvis and CXR were negative.
Alternatives include watchful waiting, chemotherapy, radiation therapy or combination, bladder sparing procedures such as radical TURBT and chemo/rads, partial cystectomy with pelvic lymph node dissection. The options for the urinary diversion are bowel conduit, bowel continent reservoir with catheterizable stoma, bowel orthotopic neobladder.
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 headache, 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: injury to obturator nerve with resultant adductor palsy and gait disturbance, lymphoceole, lower extremity edema, ureteral obstruction (5-8%), stoma problems (5-10%, stricture, peristomal hernia, prolapse, retraction, renal insufficiency), metabolic and electrolyte abnormalities potentially requiring chronic medication, ileus, bowel obstruction, impotence, impression of penile shortening, recurrent tumor formation, failure of the procedure to cure unidentified metastatic disease, urinary tract infection, pyelonephritis (10%), reservoir stone disease, increased GU stone disease (5%), fistula of ureter/bowel/reservoir (3%), wound scarring, need for chronic life-time external urinary appliance, positive margins or lymph nodes potentially requiring adjuvant radiation or chemo therapy, daytime incontinence more than once a week (5-15%), nighttime incontinence (5-25%), need for possible reoperation (3%)and positive intra-operative urethral frozen section requiring a different urinary diversion as discussed in the alternatives section.
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: __________________