Patient Name:

Age:

Date:

Procedure: Ureteroscopy for stone/filling defect

Indications:

Patient is a male/female who has a symptomatic right/left ureteral/renal filling defect/stone.

Alternatives:

Alternatives to the procedure include observation, placement of a ureteral stent, ESWL, percutaneous or open renal surgery.

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: urinary tract infection, urinary sepsis, perforation of ureter or renal pelvis, long term stent placement or reconstructive surgery to repair the injury, ureteral stricture formation, urinoma, percutaneous drainage of urinoma, urinary fistula , injury to kidney that may require removal of the kidney, injury to urethra and bladder, failure to remove all stone fragments or pathological tissue, need for additional procedures to finish the surgery to include ESWL, repeat ureteroscopy, percutaneous or open surgery, need for percutaneous renal drainage until additional procedures are completed, chronic pain syndromes, recurrence of disease process and need for future cystoscopy to remove the ureteral stents.

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: __________________