Surgery Consent Form

I understand the planned operation, the removal of pelvic lymph nodes and the prostate gland.

I understand the risk of this procedure including:

1. Impotency
2. Incontinence
3. Blood Clots 		5. Infection
6. Heart Attack
7. Intestinal Injury 		8. Nerve Injury
9. Ureteral Injury
10. Others
4. Bleeding (requiring transfusion with its possible effects, ie; Hepatitis, AIDS, and others)

Other alternative treatments have also been offered:

1. Radiation Therapy
2. Hormonal Therapy
3. Cryosurgery 		4. Seed Implantation Therapy
5. Combined Hormonal and Radical Prostatectomy
6. No treatment

Signed:     Witness:
Date:

If the lymph nodes come back positive on frozen section, I do not want Dr. Catalona to removethe prostate gland.

Signed:     Witness:

I want Dr. Catalona to remove the prostate gland regardless of whether the lymph nodes are involved.

Signed:     Witness:

I wish Dr. Catalon to perform nerve-sparing surgery, if feasible.

Signed:     Witness:

I have viewed the video on Dr. Catalona's website (www.drcatalona.com) explaining the treatment options for prostate cancer.

Signed:

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