Ureteroscopy Information and Consent Form
Patient Name
Email
example@example.com
Expaliner Video
Enter the Video Confiramtion Code
EnterPlease Enter Your 2 digit Confirmation Code
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Please Click Any Of The Following Questions To Get An Explanation
Patient Question 1: "Will I be 100% stone-free and pain-free as soon as I wake up from surgery?"
Patient Question 2: "You mentioned a 'stent'—is that just a small tube? Will I even feel it's there?"
Patient Question 3: "Is there any reason the surgery wouldn't work once you're already in there?"
Patient Question 4: "I’m worried about complications at home. How do I know if what I'm feeling is a normal part of healing or a life-threatening emergency?"
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Section A: Clinical Understanding & Success
I understand that a ureteroscopy is a surgical procedure to treat urinary stones and restore the flow of urine. I recognize that my recovery and long-term kidney health depend on strict adherence to post-operative instructions, including increased hydration and the mandatory return for a follow-up appointment to have my internal stent removed.I acknowledge that while the procedure has a high success rate for relieving blockages and fragmenting stones (typically >90%), there are inherent risks. These include the possibility of stone recurrence, urinary tract infection, or rare surgical complications such as ureteral injury. I further understand that failure to follow up for stent removal can lead to serious "late-stage" complications, including severe infection or permanent loss of kidney function, which could necessitate more invasive revision procedures.
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YES
Initial here:
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Section B: Specific Complication Disclosure
I have been informed of common post-operative side effects, such as blood in the urine (hematuria) and urinary frequency or urgency, as well as the specific "material" risks associated with ureteroscopy. These include a risk of urinary tract infection (5–10%) and the potential for sepsis (a life-threatening blood infection), both of which may require prolonged antibiotic treatment or hospital readmission.I also acknowledge the risk of stent-related discomfort, potential ureteral injury (less than 1%) such as a perforation or scratch that could lead to a permanent narrowing (stricture) of the tube, and the possibility of "failed access." I understand that if my ureter is too narrow to safely navigate, the surgeon may elect to stop the procedure and place a stent to dilate the area, necessitating a second surgery at a later date to complete the stone removal.
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YES
Initial here:
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Section C: Legal Rights & GDPR (European Standard)
I confirm this decision is mine alone and made without pressure.I acknowledge that my personal and medical data is processed in accordance with GDPR regulations.I have had all my questions answered by the clinical team and understand that I can withdraw consent at any moment prior to the procedure.
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YES
Initial here:
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