Free Ureteroscopy with Laser Lithotripsy Consent Form Template

Informed Consent for Ureteroscopy with Laser Lithotripsy

Patient Informed Consent Documentation

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

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

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