John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Patient Name:
Age:
Date:
Procedure: Sacrospinalis Fixation, possible cystoceole, rectoceole, and/or enteroceole repair
Indications:
Patient is a female with a history of vaginal vault prolapse and a possible associated vaginal wall defect (cystoceole, rectoceole, enteroceole).
Alternatives:
Alternatives include observation, vaginal pessaries and open sacroculpopexy.
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: failure of the procedure with possible open sacroculpopexy required at a later date, if cystoceole repair done it may unmask stress urinary incontinence which may require further procedures in the future to correct, vaginal vault shortening and dyspareunia.
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: __________________________________