Informed Consent for Ureteroscopy with Laser Lithotripsy

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Informed Consent for Ureteroscopy with Laser Lithotripsy

Patient and Surgical Information

Nature and Purpose of the Procedure

Ureteroscopy with laser lithotripsy is a minimally invasive endoscopic procedure performed under general or spinal anesthesia to treat stones (calculi) located in the ureter or kidney. The surgeon inserts a thin, rigid or flexible fiber-optic instrument called a ureteroscope through the urethra and bladder, and advances it into the ureter or kidney containing the stone. No external incisions are made. Once the stone is visualized, a tiny laser fiber is advanced through the scope to deliver laser energy (typically Holmium or Thulium laser) to break the stone into microscopic fragments or sand. The surgeon may extract larger fragments using a micro-basket device, while smaller fragments are left to pass in the urine. At the conclusion of the procedure, a temporary flexible plastic tube called a ureteral stent (Double-J stent) is placed in the ureter, extending from the kidney to the bladder, to prevent swelling and ensure urine flow. The procedure typically takes 30 to 60 minutes.

Ureteral Stent Placement and Symptoms

A ureteral stent is routinely placed at the end of the procedure. The stent is temporary and must be removed or exchanged, typically within 3 to 14 days after surgery, either by pulling a string left outside the urethra or during a minor in-office cystoscopy procedure. Ureteral stents cause localized irritation in most patients. Common stent-related symptoms include frequent urination, sudden urgency, burning during urination (dysuria), and mild blood in the urine, especially after physical activity. You may also experience a dull ache in your flank or kidney area when urinating, which is caused by urine refluxing up the stent. These symptoms are normal and will resolve immediately once the stent is removed.

Material Risks and Potential Complications

Ureteral stricture: scarring and narrowing of the ureter due to instrument abrasion or laser thermal energy, occurring in less than 1 to 2 percent of cases. Ureteral strictures can block urine flow and may require subsequent surgical dilation or reconstruction.
Ureteral injury or perforation: a tear or puncture in the ureter during instrument advancement or stone basket extraction, occurring in less than 1 percent of cases. This is typically managed with prolonged stent placement but can occasionally require open surgical repair.
Incomplete stone clearance: despite successful fragmentation, residual stone fragments may remain, which can cause colic pain as they pass or require a secondary procedure (such as repeat ureteroscopy or shockwave lithotripsy).
Severe urinary tract infection (UTI) or pyelonephritis: kidney infection or septicemia from bacteria released during stone fragmentation, occurring in approximately 1 to 2 percent of cases, requiring hospitalization and intravenous antibiotics.
Urinary retention or severe dysuria: difficulty urinating after catheter removal or severe discomfort due to stent irritation, which may require temporary re-catheterization or medications.

Expected Benefits

The primary expected benefits of ureteroscopy are the fragmentation and clearance of obstructing urinary stones, which relieves renal colic pain, treats or prevents urinary obstruction, and prevents progressive kidney damage or recurrent infections.

Reasonable Alternatives to Surgery

Extracorporeal shockwave lithotripsy (ESWL): using sound waves from outside the body to break the stone, which is non-invasive but less effective for hard or lower-pole kidney stones and does not allow direct visualization.
Percutaneous nephrolithotomy (PCNL): surgical removal of stones through a small incision in the back, typically reserved for very large stones (greater than 2 centimeters).
Medical expulsive therapy: taking medications (such as tamsulosin) to relax the ureter and help the stone pass spontaneously, suitable only for small, non-obstructing stones (less than 5 to 6 millimeters) without signs of infection.
Decline treatment: accepting the risks of untreated obstructing stones, which include severe chronic pain, recurrent sepsis, and permanent loss of kidney function.

Right to Refuse or Withdraw Consent

You have the right to refuse this procedure or withdraw your consent at any time before the surgery begins without penalty or adverse effect on your medical care. Your urologist will discuss the clinical risks of leaving obstructing stones untreated.

Questions and Understanding Confirmation

I confirm that I have reviewed this consent form with my urologist. I understand that a temporary ureteral stent will be placed and that I will experience stent-related urinary frequency and dysuria. I understand the small risks of ureteral injury and stricture. All my questions have been answered.

Language Access and Interpreter Services

If English is not your primary language or if you require assistance communicating, a qualified medical interpreter is available to you at no cost. Please notify your care team if you require interpreter services before signing this document.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a signed copy of this informed consent form for my own records. I understand I may request an additional copy at any time from the facility or clinical records department.

Patient Authorization

I have been informed of the ureteroscopy and laser lithotripsy procedure, its expected benefits, the material risks listed above, and available alternatives. I consent to proceed with ureteroscopy and authorize the temporary placement of a ureteral stent, which I agree to have removed on schedule.

Signatures and Verification

Patient / LAR Signature
Surgeon Signature
Witness Signature
Date and Time of Consent
Document ID: CC-PENDING
CONSENTCOLLECT