Consent for urinary incontinence surgery and anesthesia

This document is a consent form required for your upcoming surgery.

After receiving an explanation, please ask any questions you may have and complete the form.

◈ PATIENNT CURRENT CONDITION / MEDICAL HISTORY

Past Medical History  Allergies 

Constitutional abnormalities  Diabetes mellitus 

Hypertension/Hypotension  Respiratory Disease 

Heart Disease  Thyroid Disease 

Liver Disease  Bleeding Tendency 

Kidney Disease  Smoking 

Cerebrovascular disease  CurrentMedications 

Drug Side Effects  Other 

◈ Urinary incontinence surgery

Description For the name of the new year

1. Need for surgery

The surgery is required to stop or improve urinary incontinence symptoms to allow normal daily life activities.

2. Method and Detail of surgery

1. Upon arrival in the operating room, anesthesia will be administered.

2. The surgical site will be disinfected, and small incisions will be made in both groin areas and the anterior vaginal wall to insert the tape.

3.The tape will be inserted through these sites to support the urethra.

4.The incision sites will be sutured.

3.Post-operative sequelae or side effects

1.Surgery success rate:

 Recurrence rate: 10%

2.Surgical wound infection:

Prophylactic antibiotics are administered, but if an infection occurs, additional antibiotic treatment is required.

3. Bleeding at the wound site:

Bleeding may occur in the groin area, sometimes causing bruising on the inner thighs, which can last for weeks. Most cases resolve naturally without treatment.

4.Pain at the surgical site:

The tape passes through the groin muscles, which may cause pain. Severe pain may temporarily interfere with walking, but symptoms generally improve within a day.

5.Tape exposure:

During wound healing or in postmenopausal women with thin vaginal mucosa, the tape inserted into the vaginal wall may become exposed.

If tape exposure occurs, the exposed tape may need to be trimmed or the vaginal wall re-sutured.

Trimming the tape may lead to recurrence of urinary incontinence.

6.Injury to surrounding tissues:

Although the surgical method is designed to be safe, injury can rarely occur along the path of tape insertion.

Possible injuries include:

– bladder perforation

– urethral injury

– injury to surrounding blood vessels, nerves, or muscles

Additional surgery or treatment may be required depending on the injury.

7.Postoperative voiding symptoms

a) Voiding difficulty:

If the tape excessively compresses the urethra, urine flow may become weak or dribbling.

In such cases, the tape must be adjusted to relieve the pressure.

If you cannot urinate normally after catheter removal, notify the physician immediately.

Waiting for spontaneous improvement is not appropriate; with time the tape becomes fixed and harder to correct.

b) Urethral and bladder irritation symptoms:

The inserted tape or urethral catheter may cause urinary frequency or urgency.

These symptoms typically improve spontaneously, but medication may be needed.

(If overactive bladder coexists, symptom changes after surgery are unpredictable. Symptoms may worsen, requiring medication or physical therapy.)

◈ Anesthesia

1. Need for anesthesia

Anesthesia is necessary to induce blockade of sensory nerves, motor nerve blocks, and reflex nerves to maintain the optimal physiological state required for surgery. 

2. Method and content of anesthesia

2-1 Method:  Epidural anesthesia + sleep anesthesia 

2-2 Prodefure

Upon arrival in the operating room, 

basic monitoring devices will be applied,

followed by anesthesia. 

Epidural anesthesia will be performed to maintain stable anesthesia during surgery.

Immediately before surgery, sedation will be administered to relieve anxiety.

3 Post-anesthesia Complications or Side Effects

1)Conversion to general anesthesia:

If spinal/epidural anesthesia is not feasible due to the patient’s condition, or if unexpected complications occur, the anesthetic method may be changed to general anesthesia.

2)Possible side effects:

Low blood pressure, nausea, vomiting, bleeding, itching, back pain, voiding difficulty, post-dural puncture headache

3)Very rare complications:

Epidural hematoma, cauda equina syndrome, nerve injury, respiratory depression, anaphylaxis, cardiac arrest

A,side effect

Hypotension, nausea, vomiting, bleeding, pruritus, low back pain, dysuria, postdural puncture headache

B.Very rare side effects

Epidural intravacuum, coffa equina syndrome, nerve damage. Respiratory depression, anaphylaxis, heart attack

Patient Instructions Before and After Anesthesia

1.Before anesthesia

1)Fasting: No food for 8 hours prior to surgery.

2)Patients with underlying conditions must inform the medical team.

3)Continuation or discontinuation of regular medications must follow medical instructions.

2.After recovery from anesthesia

1)Report nausea, vomiting, itching, or headache to the nurse.

2)Report any sensory or motor impairment in the legs immediately.

3)If you cannot urinate within 4 hours after catheter removal, notify the nurse     immediately.

PATIENT CONSENT STATEMENT

I (or my representative) have received a full explanation from my attending physician about my current condition, the need for surgery, the surgical method, possible complications, anesthesia risks, and necessary postoperative care. I had the opportunity to ask additional questions freely, and I understand that unexpected or unavoidable complications may occur due to individual differences. I hereby consent to the surgery and anesthesia as explained and entrust my treatment to the attending physician.

Patien Name:                                                                 (Signature)

Date of Birth Contact (Mobile)

Guardian or Legal Representative                                   (Signature)

ADDITIONAL CONSENT CONDITIONS If the patient is unable to sign, please check the appropriate box below:

 Minor (under 19 years old) and unable to fully understand the content.

 Physically or mentally unable to comprehend consent information.

 Explaining the consent content may cause serious harm to patient’s mental or physical state.

 Patient has delegated consent authority to another person (attach authorization letter).

 Emergency situation where obtaining patient consent is difficult.

 Other:                     

Consent for Collection of Personal Information (for guardian/representative identification)

Date if Birth      .      .     . Sex M   /    F

Phone TEL Mobile

Address

Relationship Name                                 (Signature)

To: Director of WOOLEE Obstetrics & Gynecology Clinic