11/2023 PC 46YO F with no significant history. She consulted w/OBGYN re: heavy bleeding during periods. PC told she had uterine fibroids and was scheduled for total hysterectomy w/ BS.
1/12/24 PC had a robotic assisted hysterectomy by the same OBGYN at large metro hospital.
OP NOTE ATTACHED. No noted complications.
Did need to be admitted overnight for urinary retention. Foley was placed and had despite minimal output the next day, was discharged with instructions to follow up with OB.
1/23/24 She initially presented a few days post op for dysuria and was treated empirically for UTI by original OBGYN. Urine culture was negative. Post op check and has been reporting copious watery yellow discharge from the vagina soaking through her underwear. Reports mild lower abdominal pain and bilateral lower back pain. No bleeding.
Original OB ref her to OBGYN #2 and made her an appointment to consult w/ him the same day.
OBGYN #2 discovered ureterovaginal fistula via CT.
CT RESULT:
“IMPRESSION :
CONTRAST AND FLUID IN THE VAGINA ON THE DELAYED IMAGES, INDICATING A FISTULOUS COMMUNICATION LIKELY TO THE DISTAL LEFT URETER. PLEASE SEE ABOVE. THERE IS MILD LEFT HYDRONEPHROSIS AND LEFT URETERAL DILATATION. CLINICAL FOLLOW-UP IS RECOMMENDED. SMALL AMOUNT OF PERICOLONIC STRANDING ADJACENT TO THE DISTAL DESCENDING/PROXIMAL SIGMOID COLON, WHICH MAY REPRESENT MILD ACUTE DIVERTICULITIS OR RESIDUA OF PRIOR DIVERTICULITIS IN THIS REGION.”
2/12/2024 OB GYN #2 Performed a Robotic left ureteroneocystostomy, Retroperitoneal dissection, Ureterolysis, Psoas hitch, Cystoscopy and Retrograde pyelogram with the following findings:
“-Cystoscopy performed findings revealed the patient had extravasation of contrast from the left ureter with inability to pass a stent to the proximal area of appeared to be of complete transection. For occlusion.
-Patient found to have significant inflammation of the left ureter.
-ACE OSH was required secondary to assure the patient did not have tension of the anastomosis”
OP NOTE ATTACHED
Pt currently doing well, had foley and stent for approx 6 weeks post op. Had a few minor UTI’s since then. Continued follow up required.
We seek an OBGYN who is well versed in all procedures above and actively in practice to determine if the original OB fell below the standard in his procedure/follow up care.
We appreciate your time and opinions in advance.
Files:
No questions yet!
Do you believe there might have been medical error?
In a situation where patient has not had prior extensive surgery or evidence of either pelvic inflammatory disease or endometriosis, the ureter should be relatively easy to protect when doing a hysterectomy. In addition, one could always perform cystoscopy at the completion of the procedure to assure that urine is flowing well out of both ureteral orifices. An exception would be if the patient had very large fibroids that were altering the anatomy of the surgery which could increase the likelihood of injury to the ureter even with proper surgical technique.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Clearly the ureter was transected during the surgery by mistake and this led to all of the subsequent problems.
What makes you a good expert for this case?
As a gynecologic oncologist I am intimately familiar with the retroperitoneal anatomy, the course of the ureters, how to recognize a ureteral injury, as well as how to repair ureteral injury.
How often do you encounter cases similar to this one in your practice?
In terms of performing hysterectomies, I perform approximately 3 to 5 per week.
Do you believe there might have been medical error?
The case as described in the operative report, is a laparoscopic robotic technique, utilizing cautery techniques only. The report does outline the steps taken in very good detail also describing the size of the uterus to be greatly enlarged and apparently multi fibroid in nature. The dictation further characterizes mobilizing uterus laterally to further try and avoid injury to both ureters. The vaginal cuff is cauterized as described, and apparently closed using suture technique. At the end of the procedure, they observed peristalsis bilaterally. It is at this point where I feel the gross error has occurred. In a very complex case like this, while not standard of care, it would be highly recommended for them to perform a cystoscopy to observe for urine ejection from both ureteral orifices.. Because of the technique of cauterization, destruction of the affected ureter would’ve shown up promptly. Very slow to almost no ejection of urine from the affected ureter, could have been easily identified. At that time an attempt at catheterization of the affected ureter would’ve revealed a blockage. Remedy to the situation, could’ve been afforded very quickly, then. To simply observe, for peristalsis is very inadequate as a severed ureter in an of itself will still show peristalsis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, because of the nature of the technique used i.e. cauterization, there is only one way the blockage could have been affected. If this were a suture technique, theoretically, a kinking of the ureter could come into play from fibrosis or natural healing. Not so much with cauterization as the destructive and sealing effects of cauterizing take place instantaneously. Hence, the only way this injury occurred, was by a direct injury of the ureter itself.
What makes you a good expert for this case?
I have been in practice for 34 years, at a teaching hospital, whereby all my surgeries were attended by various levels of residents. We utilized various techniques in performing hysterectomies, and laparoscopic procedures were almost invariably performed with cauterization devices .These residents were taught all the nuances, the pros and cons of cauterization technique. I performed several hysterectomies a month during my tenure as a teaching physician and was recognized as one of the better skilled laparoscopist where I worked.
How often do you encounter cases similar to this one in your practice?
Fortunately, these are encountered fairly infrequently thanks to the level of skill and postop recognition in our hospital. From time to time they are brought up at morbidity and mortality conferences. Generally speaking, at our institution, a case like this would’ve been handed off directly to either a Gyn oncologist or urologist.
Do you believe there might have been medical error?
The operative note for the hysterectomy carefully describes the identification of both ureters prior to beginning the disection and describes an intact left ureter after removal of the uterus. That description, the urologist's description of the findings during his surgery and the interval between the hysterectomy and the appearance of urine draining from the vagina all are consistent will thermal injury to the ureter from the monopolar cautery used to detach the uterus. The thermal injury would not be apparent at the time of the injury, but evolve postoperatively. Unfortunately, ureteral injury is a recognized risk of hysterectomy and, in this case occurred despite the gynecologist's well documented, careful use of correct technique.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Clearly, the ureteral injury was a complication of the hysterectomy, but was not a "medical error".
What makes you a good expert for this case?
I have had extensive experience doing laparoscopic hysterectomy.
How often do you encounter cases similar to this one in your practice?
I've never had a ureteral injury as a complication of my many hysterectomies, but is a recognized complication.
Do you believe there might have been medical error?
The operative report documented having visualized the bilateral ureters. Peristalsis doesn’t guarantee functioning ureters without obstruction, but during a hysterectomy, being able to visualize the ureters is usually the best way to have avoided injury. One might be able to say if there were some suspicion for injury, a diagnostic cystoscopy can be done at the end of the procedure, but that is not necessarily routine and care was taken to avoid ureteral injury. The described procedural steps for the hysterectomy, specially left uterine artery dissection, is consistent with a routine procedure. Also, the presentation and workup was that of ureterovaginal fistula, but second operative findings were that if ureteral transaction - something doesn’t quite add up
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
N/A see above - from the operative report it is difficult to ascertain error; if anything, care was taken to ensure ureteral damage was avoided. The only additional thing would have been to do cystoscopy to have diagnosed the injury at time of surgery, which is not a universal practice
What makes you a good expert for this case?
I am 13 years out of OBGYN residency and 10 years out of gynecologic oncology fellowship, and have been consulted by my colleagues on cases of injuries similar to this.
How often do you encounter cases similar to this one in your practice?
Once every year or so will get consulted on similar case. A few times a year I will encounter incidental/unavoidable ureteral injury/transection due to cancer involvement
Do you believe there might have been medical error?
This case is almost certainly one of delayed thermal injury. This can happen despite meticulous surgical technique, due to the proximity of the ureter to the uterine artery at the level of the internal os, where the artery is generally cauterized.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Although I don't believe that there was "medical error," the delayed thermal injury caused the fistula which resulted in the necessity for a reimplant.
What makes you a good expert for this case?
I perform about 100 robotic hysterectomies annually, and am extremely familiar with the ins and outs of such cases. Furthermore, I have testified in court several times in cases involving such injuries.
How often do you encounter cases similar to this one in your practice?
I do many hysterectomies every year. I don't recall having any of these injuries involving my own pts, but I have reviewed many (both plaintiff and defense).
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