Counseling and Pre-Op Note

Patient Name:



Procedure: Radical retropubic prostatectomy with or without nerve sparring techniques


Patient is a male with a diagnosis of prostate cancer determined with needle biopsy of the prostate performed for an abnormal digital rectal exam and/or an elevated PSA blood test. The pathology report showed the cancer to have a Gleason sum of X + X = X. If the PSA was above 10.0 or the Gleason sum was greater than or equal to 8 the metastatic evaluation of CXR, bone scan and/or CT of the pelvis was without evidence of distant spread.


Alternatives include watchful waiting, radiation therapy (external beam and radioactive seed placement), cyrotherapy, and hormonal therapy. Surgical options are retropubic or perineal prostatectomy.


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: impotence, incontinence, urinary tract infection, bladder neck contracture, rectal injury which may be severe enough to require a fecal diversion procedure with a colostomy and then future reattachment of the colon, fecal incontinence, loss of ejaculatory function, change in the character or loss of orgasm, chronic pain of the epididymus or testicle, additional procedures may be required in 30% of patients for incontinence that include: urethral bulking agents; male sling; or artificial urinary sphincter placement, 50-80% for impotence to include: oral agents; vacuum tumescence devices; penile injection therapy; intraurethral agents; and or penile prosthesis placement, 10-15% for bladder neck contracture to include: bladder neck incision; dilation therapy and laser ablation of the stricture, positive surgical margins or seminal vesicle invasion potentially requiring adjuvant radiation therapy or hormonal therapy. If palpable lymph nodes are detected during the procedure and confirmed to contain prostate cancer on the frozen section the procedure will be halted at the patients request (pre-operative decision). Patient also needs to realize that frozen section diagnosis could have significant error. The addition of PLND could cause a lymphoceole, which may require prolonged percutaneous drainage, lymph edema of the lower extremities, injury to the obturator nerve which will cause inability to move legs to midline and cause a gait disturbance.

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: __________________________________