Patient Name:

Age:

Date:

Procedure: Right/left/bilateral testicular exploration

Indications:

Patient is a male with possible torsion of the testes. Physical exam reveals an absent cremasteric reflex and a Doppler ultrasound that shows diminished blood flow to the involved testicle. Attempts as detorking the testicle have failed.

Alternatives:

Alternative is observation and pain control.

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: injury to spermatic vessels, testicle and vas deferens which may lead to loss of testicle or future infertility problems. Loss of testicle may occur even if the torsion is reversed, it is at the discretion of the operating surgeon as to whether or not the viability of the testicle is such that it is either removed or pexed and observed. Possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal skin. This exploratory surgery may reveal normal contents in the scrotum and no evidence of a testicular torsion.

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: __________________