Orders, Surgical Consent and Patient Information
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Enter surgeon last name: John Milner, M.D.
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Enter the diagnosis: Prostate cancer
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John Milner, M.D.
2160 South First Avenue
Maywood, IL 60153
Name: Pickett, Wilson Date: 21 August 2011
Diagnosis: renal tumor
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: Pickett, Wilson
Consent for Surgery MR#: 1234567
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: Wilson Pickett
Procedures: Radical Prostatectomy [removing the prostate gland and lymph nodes]
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): renal tumor
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 be by
Possible Complications: Impotence [inability to get or keep an erection] (%), Incontinence [inability to
control urine leakage] (%), bleeding (<5%), lymphocele [collection of lymph fluid in the pelvis] (%),
infection (<5%), injury to the intestines or other organs (<1%), hernia through the incision (<1%),
inability to remove all of the tumor (<5%), others
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 were 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 and diagnostic procedures referred to above 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), therapy(s) or procedure(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) or procedure(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
How is a prostate removed?
The prostate lies in the pelvis between the bladder and
the urethra (urine channel). It is removed through an
incision between the umbilicus and the pubis bone.
Lymph nodes are removed in order to see if the cancer
has spread outside the prostate gland. An incision is
made, separating the prostate from the bladder and
another incision is made, separating the prostate from
the urethra. After the prostate is removed, the urethra
is then connected directly to the bladder. A catheter is
left in the urine channel for about two weeks to allow
the re-connection to heal. A drain is placed in the
pelvis that comes through the skin on the lower
abdomen in order to allow any fluid that might collect
around the surgical site to drain. The muscles are sewn
together and the skin is closed (usually with staples).
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 impotence [difficulty having and/or keeping an erection).
Because the nerves that are necessary to have an erection lie very near to the prostate gland, removing the prostate can interrupt
these nerves or cause inflammation that keeps these nerves from functioning normally. Sometimes the cancer is so close to the
nerves that in order to remove the cancer, it is necessary to remove the nerves, too. If you had full erections before surgery, you
may 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 second most common complication of prostate removal is incontinence. Normally, two control muscle systems, called
sphincter (sfink-ter) muscles, close the urine channel, preventing urine from leaking. When the prostate is removed, one of
those sphincters is removed. Most of the time, the remaining sphincter keeps urine drainage under control. 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.
When the prostate is removed, lymph channels are cut. Sometimes this causes lymph fluid to collect in the pelvis. This is
called a lymphocele and it occurs in a small number of patients after prostate surgery. Anytime we operate around large blood
vessels, 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. It might also be necessary to place a drain catheter or to perform a
second surgery to drain an infection pocket. Serious infection is rare after this surgery
Because other organs lie near the prostate, they need to be moved in order to remove the prostate. It is possible that those
organs (intestine, etc.) could be injured during the surgery. If so, a repair surgery would be required. This is quite rare. It is
possible that the muscle tissue might not heal together following any surgery causing a hernia. If that happens, a hernia repair
surgery would be necessary. Fortunately, this is very rare.
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 2-3 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 medicine through an intravenous line so you won’t need a shot. Your surgeon may order a
computerized pump (Patient Controlled Analgesia or PCA). This will allow you to take a dose of pain reliever when you feel
you need it. It is important that only you use the pump. We usually use PCA until the second day following surgery. Some
patients will receive ketorolac (a strong cousin of ibuprofen) through an intravenous line for pain. Within one or two days after
surgery we will start pain pills that you can take at home. Most people need to take pain medicine at home for 3-4 weeks
following the surgery. However, because each person is unique, it is impossible to predict how long you’ll need to take pain
When will I be able to eat?
Most patients can start drinking liquids the day following surgery. Solid food follows rapidly unless there are concerns about
the bowels moving. Many 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.
When can I go back to work?
You should plan to take about 2 months 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 brief shower (5-10 minutes) starting two days following the surgery. You may let the water run over the
incision. One week after your surgery, you can stay in the shower or bath as long as you like.
How long will it take before I feel “normal?”
Most patients tell us that it takes approximately 6-10 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 organs that produce semen are removed. You may notice that your penis is not
as long as it was before surgery. 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
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
Patient Pathway for Radical Prostatectomy
Before Surgery Day of Surgery Post op Day 1 Post Op Day 2-3 1 week Clinic Visit 2 week Clinic Visit
with Nurse with Physician
Activity Your normal activity Deep breathing exercises Deep breathing exercises Going Home Walk 3 x daily Walk 3x daily
Up in chair Sit in chair No heavy lifting No heavy lifting
Walk in room Showers-no bath Showers-no bath
Ok to climb stairs Ok to climb stairs
Nutrition Clear liquids only Ice Chips Normal Diet Normal Diet Normal Diet Normal diet
Nothing to eat or Clear liquids Drink plenty of fluids
drink after midnight
Medications Take usual Pain pills Begin antibiotics day
medications only as Antibiotics before catheter is to be
directed. Tell your Stool softener removed
surgeon if you are
aspirin, ibuprofen or IV fluids
Treatments & Bowel preparation lab work
Tests Vital signs
Tube Care JP drain collects pelvic JP removed Clinic nurse will Catheter will be
fluid Home with catheter remove staples removed
Catheter keeps bladder
Education & Make arrangements Be sure to ask any questions Learn about catheter care Review pathology and
Discharge for going home you may have plan more treatment if
Planning Purchase incontinence needed
Learn and practice Begin Kegel exercises
Kegel exercises prior after catheter removed