Patient Name:

Age:

Date:

Procedure: Tension-Free Vaginal Tape (TVT)

Indications:

Patient is a female with a history of genuine stress or mixed urinary incontinence and an associated vaginal wall defects (cystoceole, rectoceole, enteroceole). She is aware that the sling material is prolene mesh.

Alternatives:

Alternatives include conservative therapy with estrogen therapy, Kegel exercises, pharmacotherapy, behavioral/biofeedback/electrical stimulation therapy, transurethral injection of bulking agents, pessaries, urethral plugs, pubovaginal slings and bladder neck suspensions.

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: chance of urethral obstruction and need for Clean Intermittent Catheterization (CIC) until obstruction resolves which could be months, an additional procedure may be required to relieve the obstruction, continued incontinence, new onset of irrative voiding symptoms, urgency and urge incontinence, injury to urethra/bladder/rectum/small bowel, there could be chronic infection or erosion of the prolene mesh, and vesicovaginal fistula.

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: __________________