John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Patient Name:
Age:
Date:
Procedure: Direct Vision Internal Urethrotomy (DVIU)
Indications:
Patient is a male with stricture disease of the urethra.
Alternatives:
Options include prolonged urethral dilation with clean intermittent catheterization (CIC), direct vision internal urethrotomy, laser ablation of stricture, Urolume stent placement, open urethroplasty, or open graft urethroplasty.
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: prolonged urethral catheterization, urethral diverticulum, urethral abscess, recurrence of the stricture, future alternative procedures for failures, prolonged dysuria, penile pain and impotence.
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: __________________________________