608 CHAPTER 16 Urological surgery and equipment

Consent: general principles

Consent is required before you examine, treat, or care for a competent adult (a person age 16 or older).

Think of obtaining consent as a process rather than as an event. In order to give consent, a patient must understand the nature, purpose, and likely effects (outcomes, risks) of the treatment. From the information they receive, the patient must be able to weigh the risks against the benefits and so arrive at an informed choice. They must not be coerced into making a decision (e.g., by the doctor in a hurry). Giving the patient time to reach a decision is a good way of avoiding any accusation that they were pressured into a decision.

To reiterate—think of consent as a process rather than as an event.

Giving information

How much information should you give? What options and risks should you mention? A doctor is not guilty of negligence if he or she acted in accordance with a practice accepted by a responsible body of medical people skilled in that particular art. (That body of medical people must be a competent and reasonable body and the opinion expressed must have a logical basis—the Bolitho modification of the Bolam defense.)

You have a duty to discuss the range of treatment options available (the alternatives), regardless of their cost, in a form the patient can understand, as well as the side effects and risks that are relevant to the individual patient’s circumstances.

A risk is defined as a material one (one that matters, one that is important) if a reasonable person in the patient’s circumstances, if warned of that risk, would attach significance to it (e.g., loss of the tip of a little finger may be of little long-term consequence to many people, but for the concert pianist it could be a disaster). Thus, the amount and type of information you give is different in every case.

Remember, it can be argued that the consent was not valid because the amount of information you gave was not enough or was in a form the patient could not understand.

Recording

Remember to record the consent discussion in the notes. If you do not record what you said, you might as well not bother saying it. If a patient later claims that they were not told of a particular risk or outcome, it will be difficult to refute this if your notes do not record what you said.

Writing “risks explained” is inadequate. When cases do come to court, this is usually several years after the events in question. You will have forgotten precisely what you said to the patient and it will not take much effort of a lawyer to suggest that you might not have said everything that you thought you said. If you give a written information sheet, record that you have done so and put a copy of the version you gave in the notes.

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The consent form

The consent form is designed to record the patient’s decision and, to some extent, the discussions that took place during the consent process (although the space available for recording the discussion, even on the consent form, is limited). It is not proof that the patient was properly informed—that valid consent was obtained.

Avoid, if possible, technical abbreviations such as TURBT. A patient could reasonably claim not to have understood what this was.

Try to avoid standing over the patient, waiting for them to sign the form. It is good practice to leave the form with the patient and to return after a few minutes—they will feel less pressured and can ask further questions if they wish.

Children

Children less than 16 years of age may give consent as long as they fully understand what is involved in the proposed examination or treatment (a parent cannot override the competent child’s consent to treatment).

However, a child cannot refuse consent to treatment (i.e., a parent can override a child’s refusal to consent—the parent can consent on the child’s behalf if the child refuses consent, though such situations are rare).

610 CHAPTER 16 Urological surgery and equipment

Cystoscopy

Cycstoscopy is a basic skill of the urologist. It allows direct visual inspection of the urethra and bladder.

Indications

•Hematuria

•Irritative LUTS (marked frequency and urgency) where intravesical pathology is suspected (e.g., carcinoma in situ, bladder stone)

•For bladder biopsy

•Follow-up surveillance of patients with previously diagnosed and treated bladder cancer

•Retrograde insertion of ureteric stents and removal

•Cystoscopic removal of stones

Technique

Flexible cystoscopy

A flexible cystosope is easily passed down the urethra and into the bladder following instillation of lubricant gel (with or without local anesthetic). This is principally diagnostic, but small biopsies can be taken with a flexible biopsy forceps, small tumors can be fulgurated (with a diathermy probe) or vaporized (with a laser fiber), and JJ stents can be inserted and removed using this type of cystoscope.

Rigid cystoscopy

This is a rigid, metal instrument that can be passed under local anesthetic in women (short urethra), but usually requires general anesthetic. It is preferred over flexible cystoscopy when deeper biopsies will be required or as an antecedent to TURBT or cystolitholapaxy when it is anticipated that other pathology will be found (tumor, stone).

The flexible cystoscope uses fiber optics for illumination and image transmission. It can be deflected through 270°.

Common postoperative complications and their management

Mild burning discomfort and hematuria are common after both flexible and rigid cystoscopy. These usually resolve within hours.

Procedure specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of flexible cystoscopy

Warn the patient that if the cystoscopy is being done because of hematuria, it is possible that a bladder cancer may be found, which may require further treatment. You should specifically seek consent for biopsy (removal of tissue if an abnormality is found).

Common

•Mild burning or bleeding on passing urine for a short period after operation

•Biopsy of an abnormal area in the bladder may be required.

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Occasional

• Infection of bladder requiring antibiotics

Rare

•Temporary insertion of a catheter

•Delayed bleeding requiring removal of clots or further surgery

•Injury to urethra causing delayed scar formation (a stricture)

Serious or frequently occurring complications of rigid cystoscopy

•As for flexible cystoscopy

•Use of heat (diathermy) may be required to cauterize biopsy sites.

•Very rarely, perforation of the bladder can occur, requiring temporary insertion of a catheter or open surgical repair.