Orders, Surgical Consent and Patient Information
Laser Photovaporization Prostatectomy
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Enter the diagnosis: Prostate enlargement/urine obstruction
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John Milner, M.D.
2160 South First Avenue
Maywood, IL 60153
Name: , Date: 19 May 2011
PT/PTT – INR
Urinalysis [dip stick]
Urine culture & sensitivity
Type and cross ___ Units P.R.B.C.
John Milner, M.D.
Loyola University Medical Center Name: ,
Consent for Surgery MR#:
1. I hereby authorize Dr. John Milner, M.D., attending physician, and such assistants and associates as may be elected by him/her to
perform the following procedure(s) upon:
Procedures: Laser Photovaporization of the Prostate [removing prostate gland tissue using a laser in a
telescope placed through the urine channel]
2. I understand that this procedure(s) appears to be indicated by the diagnostic studies and/or clinical observations already performed
regarding the following condition:
Condition requiring the procedure(s):
3. I authorize the administration of anesthesia as may, in the exercise of good professional judgment, be necessary or advisable by
the physician responsible for administering anesthetics.
4. I authorize the administration of blood and blood components as may be considered necessary or advisable in connection with
the procedure(s) described above.
5. The nature, purpose, and possible complications of the procedures and medical services described above, the risks and benefits
reasonably to be expected, and the alternative methods of treatment and the risks/benefits of no treatment have been explained to me
by my physician.
Possible Complications: Continued blackage of urine flow, Incontinence [inability to control urine
leakage], Bleeding, Infection, Impotence [inability to get or keep an erection], injury to other organs,
6. I recognize that during the operation unexpected conditions may be revealed which require my doctors to perform additional or
different procedures than those described above. Since I may be under anesthesia or otherwise unable to give my consent to this
treatment during the procedure(s) described above, I hereby authorize and request that the physician performing these procedure(s) and
his assistants or designees perform such other procedures as are, in the exercise of good professional judgment, necessary and
desirable. I understand that these procedures may include surgery as well as other forms of treatment. The authority granted in this
paragraph shall extend to remedy all conditions found during the operation that require treatment, and that are not known at the time
the procedure is commenced.
7. I acknowledge that I have received no warranties or guarantees with respect to the benefits to be realized or consequences of the
8. I consent to the filming or recording of the procedure to be performed, including appropriate portions of my body, for scientific or
educational purposes which arenot related to diagnosis or treatment of my condition, provided my identity is not revealed by the
pictures or by descriptive texts accompanying them. I understand that I can revoke this consent for filming/recording by notifying my
attending physician within five days of my surgery or procedure. In the event of revocation, I understand that any prior us of film or
recordings up to the date of revocation may not be retracted.
9. For the purpose of advancing medical education, I consent to the participation of residents, fellows and health care students in the
surgery or procedure and to the admittance of observers to the room in which the surgery or procedure(s) are performed. These
observers may include representatives from medical device manufacturing companies who are demonstrating or providing technical
support for new procedures or equipment.
10. I consent to the disposal by hospital authorities of any tissues, body parts or implants which may be removed.
11. I acknowledge that I have read this document in its entirety and that I fully understand it, that all blank spaces have been
completed and that any disagreeable sections have been crossed off and initialed prior to my signing.
12. I understand that I have the right to cancel my surgery at any time, even after I have signed this consent form. I understand that I
am under no obligation to proceed with the surgery.
13. I have had a full discussion about the proposed procedure with my physician and have consented to the procedure described on
this form. I further understand that if I have questions about my proposed surgery or procedure, I have the right to have those
questions answered before surgery or procedure.
Date Time Print Name Signature of Patient
Print Name Signature of Consenting Party Relationship to Patient
AFFIRMATION OF INFORMED CONSENT BY PHYSICIANS
I have informed the above-named patient or the patient’s authorized representative, of the condition requiring
treatment(s), therapy(s) or procedure(s) described to on the front page of this Consent Progress Note and I have,
consistent with my best medical judgment, fully explained the nature and purposes of all the treatment(s),
therapy(s) or procedure(s), possible alternative methods of treatment(s), the risks involved and the possibility of
complications in the treatment(s), therapy(s) or procedure(s) consented to and in alternative treatment(s),
therapy(s) and procedure(s), and that, after the foregoing information had been explained, the patient or
representative indicated that he/she understood that information and consented to such treatment(s), therapy(s)
Date John Milner, M.D.
I affirm that I acted as interpreter or translator for the patient or the patient’s representative and accurately and
completely translated into the _________________________ language both the statements contained on this
form as well as the statements made by the physician, John Milner, M.D., to the patient and/or the patient’s
representative and that the patient or the patients representative stated that he or she understood all of the
statements and consented to the treatment and/or other procedures described in those statements.
Relationship to Patient Print Name
Patient or Consenting Party signed this form in my presence or consented by telephone
If an RN is witnessing the signature, a properly executed Consent Progress Note must be in the medical record.
Witness (print name and title) Signature Date
Additional Witness (For telephone consent, interpreter or, translator or if patient signs with an “X”) Signature Date
Information for Patients about
Laser Prostate Surgery
How is a prostate removed?
The prostate lies in the pelvis between the bladder
and the urethra (urine channel). The prostate wraps
around the urine channel like a ring. Prostate glands
grow with age. About one in four men has difficulty
passing urine as his prostate grows and creates a
blockage. Your surgeon has recommended that you
have laser prostate surgery. This surgery is
performed through a special telescope called a
This instrument has a channel through which a laser
fiber can be passed. The laser beam is aimed at the
prostate tissue, heating the tissue enough to destroy
it. The laser also controls bleeding. The procedure
takes about one hour. After the surgery a catheter is
placed in the bladder to drain the urine and control
bleeding. This catheter usually stays in place for 1-2
weeks. Pieces of the prostate may pass through a
bladder catheter or through the urine channel after
the catheter is removed.
Although no outside incision is made during this surgery, it is still considered major surgery. You should plan to
limit your activities and avoid doing any stressful physical activity. If you do too much, you may cause the prostate
to bleed. While you are in the hospital and shortly after you arrive back home, your urine may have a significant
amount of blood. This is normal. If you notice blood clots in your urine, or if you have trouble urinating, please
call us immediately. Within several days, your urine will clear up. Then, about 10-14 days after surgery, you will
probably have another 1-2 days of bloody urine. This is normal.
What are the possible complications of having a prostate removed?
Although we try our best to do everything possible to make the surgery safe, there are potential complications of the procedure.
The most common complication following prostate removal is continued blockage of urine. We try to treat just the right
amount of prostate tissue and most of the time the surgery is very successful at relieving blockage and improving urine flow.
Sometimes the urine stream is slow immediately after the bladder catheter is removed. This is usually caused by inflammation
of the remaining prostate tissue and incomplete break-up of the heated tissue.
Some men have trouble controlling urine (leakage with coughing, sneezing or straining as with lifting) after prostate surgery.
Some men notice urine leakage with coughing, sneezing or straining after prostate removal. Rarely, a man may not have any
control of urine drainage following prostate surgery. Medical and surgical treatments are available if this happens.
Impotence (difficulty having and/or keeping an erection) is a very rare problem following this type of prostate surgery.
Inflammation caused by the surgery may prevent the nerves that control erection from functioning normally. If you had full
erections before surgery, you will probably have full erections following prostate removal. You may notice having more
difficulty getting an erection. Some men are able to have an erection, but they find that it is not as firm or it does not last as
long as it did before surgery. Often, this improves with time. Many surgeons recommend using a medication and/or having
sexual activity within a few weeks of prostate removal because doing so has been shown to improve the ability of prostate
patients to have erections firm enough and for long enough to have sexual intercourse. If a man is unable to have an erection
after prostate removal, treatment (medication or surgery) may help.
The prostate gland has many blood vessels, so there’s always a possibility of some bleeding. If bleeding occurred, a blood
transfusion or a second surgery may be necessary. This is not common. Infection is also possible following major surgery such
as this. If an infection occurred following a prostate removal, antibiotics may be necessary.
As with any major surgery, it is possible that a blood clot in the leg, a blood clot traveling to the lung, or pneumonia could
develop following prostate surgery. We take special precautions to try to prevent such complications. This includes having
patients cough and take deep breaths regularly to keep the lungs opened up. We also encourage patients to walk starting the
day following the surgery. Other more rare complications could also occur. If you have specific questions, please ask your
How long will I stay in the hospital?
Most patients are ready to leave the hospital 1-2 days after surgery. Of course, each patient is unique, so your hospital stay
could be longer. When you are eating regular food, when your pain is controlled with pain pills and when you are able to do
the physical activities necessary at home, you will be ready to leave the hospital.
How much pain will I have? What can you do to control the pain? How long will the pain last?
These are some of the most difficult questions to answer because each person experiences pain in a different way. Following
your surgery, you will be given pain pills that you can take at home. Most people need to take pain medicine at home for less
than a week following the surgery. However, because each person is unique, it is impossible to predict how long you’ll need to
take pain pills.
When will I be able to eat?
Most patients can start drinking and eating following surgery. Some patients notice that their appetite isn’t as strong for a few
days following surgery.
When can I drive again?
We recommend that you not drive until you no longer need narcotic pain medication. These medications can alter your ability
to respond quickly in an emergency situation. You should not sit in one place for more than 45 minutes for four weeks
following your surgery. You should not drive or sit in a car for more than an hour for at least a month.
When can I go back to work?
You should plan to take about 4-6 weeks off work. Some patients are ready to go back to work sooner and some are ready later
than four weeks. You will need to listen to your body to know when you are ready. It may be helpful to return to work part-
time or doing light work at first. If you need a letter for your employer, let us know.
What physical activities can I do following the surgery?
After you get home from the hospital, you should plan to do a little walking every day. Start slowly and gradually build up your
endurance. If you overdo it, you will be sore. Listen to your body and use your head. Starting 2-3 weeks following the
surgery, you may begin to do some stretching exercises that will help you to stay limber. Starting three weeks following the
surgery, you may begin to do some light exercise. Gradually build up your exercise plan over the next four weeks.
One of the most frustrating things that surgical patients complain about is lack of energy. Major surgery takes a lot out of a
person. When you think about spending 3-4 weeks at home, away from work, you will probably think of some projects around
the house that you’d like to finish such as cleaning out a closet, organizing the garage, doing some yard or housework, etc. We
advise you to put all those plans on hold for a while. It will be better for you to plan to read some good books, watch movies,
listen to music or try some low energy hobbies. Plan to do things that will keep your active mind busy while your body is
When can I shower?
You can take a shower starting the day following the surgery.
How long will it take before I feel “normal?”
Most patients tell us that it takes approximately 4-6 weeks before they feel back to “normal.” Remember, there is a lot of
variation from one person to another. Don’t get discouraged if you don’t feel back to 100% six weeks following your surgery.
Will I need to eat a special diet after the surgery?
No. You can eat anything you would like. Of course, we recommend that you eat a healthy diet including plenty of fresh fruits
Can I drink alcohol?
Yes. As with your diet, we recommend moderation.
What about sex?
As with other physical activities, you should take it slowly. Wait until you’re ready and don’t overdo it. Listen to your body.
You may want to try some non-intercourse sexual activities until you’re feeling better. You may notice that you have difficulty
getting or keeping an erection following your surgery. It is helpful for you to try to have an erection regularly after surgery.
This will help you keep your ability to have an erection or improve it. After the prostate is removed, no semen (cum) will come
out of your penis during sex. This is because the semen flows backwards into the bladder. This does not mean that you or your
partner will not enjoy sex as much following surgery, but it may be different. If you have trouble with sexual function, please
let your surgeon know. Treatment is available for these problems.
What if I have other questions?
We’re happy to answer all of your questions. It may be best to write down questions as you think of them. Please call your
surgeonr with any questions you may have.
Department of Urology Office: 708/216-4076
Loyola University Medical Center Appointments:
2160 S. First Avenue Central Scheduling (all clinics) 708/216-8563
Maywood, IL 60153
Postoperative Pathway for Patient Undergoing Laser Prostatectomy
Before Surgery Day of Surgery Post op Day 1 Post op Day 2 Post Op Day 3-4 Clinic Visit _ week
Activity Your normal Deep breathing Going home Deep breathing Walk
activity exercises exercises No heavy lifting
Sit in chair Sit in chair Showers-no bath
Walk in room Walk in hall Ok to climb stairs
Nutrition Clear liquids only Liquids or normal Ice chips Normal diet Normal diet
Nothing to eat or diet when bowel Drink plenty of fluids
drink after function returns
Medications Take usual Restart oral Usual meds
medications only as medications when
directed. tolerating food
Tell your surgeon Pain pills
if you are taking
aspirin, Coumadin, IV
ibuprofen or Plavix fluids
Treatments & lab work
Tests Vital signs
Tube Care Foley catheter removed Staples removed at
Catheter drains one week visit
Education & Make Be sure to ask any Learn about care of your incision
Discharge arrangements for questions you may
Planning going home have