We are seeking expert review regarding the urologic care provided in connection with an elective vasectomy and hydrocelectomy, and the complications that followed. We ask that you assess whether the care met the applicable standard at key junctures between February and April 2023.
Facts:
On February 27, 2023, the patient underwent elective vasectomy and hydrocelectomy with bilateral drain placement. On March 1, 2023, he presented to the emergency department with severe groin and flank pain (10/10), scrotal swelling, asymmetric drain output, leukocytosis, and an abnormal urinalysis. He was discharged without scrotal imaging despite a urologic consultation with the provider who performed the vasectomy and hydrocelectomy.
At his post-operative follow-up on March 7, 2023 with the same provider who performed his surgeries, the patient reported persistent severe pain, though the chart notes documented that he was “doing well.” No ultrasound was obtained. On March 22, 2023, he returned again, at which time a scrotal ultrasound showed absent vascular flow to the left testis, consistent with infarction, and heterogeneous material concerning for hemorrhage and necrosis.
By March 27, 2023, he had developed a scrotal abscess and testicular infarction requiring left orchiectomy. He reported pain at the external ring of the left inguinal canal, with mild erythema and tenderness on exam. Two days later, on March 29, his symptoms began to improve, with decreased pain and redness. He was pr escribed Bactrim based on culture sensitivities, and at a March 31 visit, showed continued improvement with resolution of erythema and tenderness. At follow-up on April 17, 2023, he reported some resolution of pain at the inguinal site, having completed antibiotics and with no ongoing documented complications at that time. However, despite surgery and antibiotics, complications continued. By mid-2024, he had developed a large scrotal fluid collection with persistent drainage and skin breakdown, raising concern for chronic wound, infection, or fistula.
Theory:
A central issue is whether scrotal ultrasound should have been performed at the emergency visit shortly after surgery on March 1, 2023 or shortly after that. The patient reported severe pain, swelling, drainage abnormalities, leukocytosis, and an abnormal urinalysis—findings that strongly supported the need for imaging. There are also discrepancies between the patient’s reported complaints of severe pain at follow-up visits on March 7 and March 22 and contemporaneous medical documentation that described him as “doing well” and “denying pain.” These conflicting records may complicate expert review but highlight potential deficiencies in clinical assessment and documentation.
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Do you believe there might have been medical error?
In my opinion, when the patient returned to the emergency department several days after scrotal surgery with severe pain, my concern would include possible infarction of the testis, possible infection, or hematoma. I am more concerned with vascular compromise of the testis considering he had not only a hydrocelectomy, but also a vasectomy. A scrotal sonogram would allow one to identify the presence of vascular flow to the testicle and possible emergent exploration in an attempt to correct the problem. If in fact, this was a significant hematoma leading to compression of the cord or a torsion both could be corrected with emergent re-exploration
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Clearly, all this patient’s issues happened after his surgical procedure. The loss of the left testicle that was noted about a month afterward likely presented during his ER visit. It is possible that an exploration at that time could have saved the testicle and maybe lessened his continued uncomfortable postoperative course, which eventually led to an orchiectomy.
What makes you a good expert for this case?
As chief of my division, I regularly perform scrotal surgery and commonly review departmental cases which have complications.
How often do you encounter cases similar to this one in your practice?
Yes, we review all cases of complication, including minor complications that do not require intervention. We certainly have seen cases where patients are status post hydrocelectomy have hematomas. Almost universally these patients have imaging performed.
Do you believe there might have been medical error?
Yes, i believe the standard of care was not met as no ultrasound was performed earlier to help diagnose the issue.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, I believe that inadequate evaluation was done after patient presented to ER with pain.
What makes you a good expert for this case?
I a am fellowship trained, board certified urologist with many years experience with great credentials and who performs these surgeries at a high volume.
How often do you encounter cases similar to this one in your practice?
These are common surgeries that I do but certainly this is an uncommon but known complication
Do you believe there might have been medical error?
As presented, this is a very unusual case. Based on the description of the case, if the patient was in the ED (as opposed to Urgent Care), with significant scrotal swelling and pain and flank pain 2 days following hydrocelectomy and bilateral vasectomy, it would have been prudent to obtain a scrotal US as a minimum, and if flank pain, a renal US. EDs are typically able to obtain emergency scrotal US to assess testicular blood flow.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If a scrotal US had been performed, it might have shown decreased or absent flow to the testicle, as well as possibly a hematoma. If the surgeon was aware of this issue, they might have decided to explore the testicle to try to determine why there was decreased or absent blood flow. However, if the blood flow was compromised, it is likely that they would not have been able to save the testicle. However, if there was partial blood flow to the testicle, it is possible that a vasodilating agent such as papaverine could have been administered to the spermatic cord to improve blood flow. The details of the hydrocelectomy and vasectomy are not available to review. Sometimes hydrocelectomies are quite difficult and if the hydrocele is large, recurrent hydrocele and/or hematoma are known complications. If a vasectomy is done, typically the deferential artery is ligated also, which is a secondary source of blood flow to the testicle. It is possible that the initial surgical procedure caused medical error, but further information is necessary.
What makes you a good expert for this case?
I am a board certified urologist who specializes in pediatric urology and perform many hydrocelectomies in young children as well as adolescents.
How often do you encounter cases similar to this one in your practice?
This is a highly unusual case. Absent blood flow to the testicle following a hydrocelectomy is very unusual.
Do you believe there might have been medical error?
What side was the hydrocele? What side was the pain? Was it bilateral? Your summary is not complete
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It appears that a vascular injury most likely occurred.
What makes you a good expert for this case?
Been in practice for 30 yr and do a large amount of scrotal surgeyr
How often do you encounter cases similar to this one in your practice?
I have never had a case with this outcome and result in loss of testicel
Do you believe there might have been medical error?
On the immediate post-op visit, I think appropriate care was given and the patient was provided reassurance; most of his symptoms could be attributed to post-operative swelling and pain. However, I think there was a significant lapse of medical judgment and delayed care upon his second post-operative presentation one week after surgery. Given the constellation of severe pain, persistent drainage, and leukocytosis, at the minimum, this should have raised red flags about a range of complications including potential vascular or infectious etiologies. I would strongly contend that the patient should have had scrotal imaging upon his second post-operative visit on March 7th. This should have included scrotal ultrasound with Doppler to document presence or absence of vascular flow to the compromised testis. With the more timely diagnosis, the patient may have undergone earlier surgical intervention which may have resulted in less downstream complications. In hindsight, the patient likely suffered testicular infarction during or immediately after surgery, the potential mechanism of injury likely due to devascularization secondary to concurrent vasectomy as well as aberrant testicular artery anatomy given his prior surgical history. In other words, he likely suffered "two-strikes hypothesis" against the testicular artery as well as concurrent loss of the vas deferens artery, which rendered the testis with inadequate blood supply to support viability.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is impossible to know when the testicle suffered infarction, the most likely etiology for the injury happened in the perioperative when severe pain was reported by the patient. It is very unlikely that earlier surgical intervention would have saved the testicle since it only takes a few hours for testicle infarction and subsequent tissue necrosis. However, it is my contention that earlier imaging and a priori earlier surgical intervention may have significantly reduced the risk of downstream wound complications including fistula, chronic drainage, and skin breakdown. Due to the delay in care and festering tissue necrosis, this likely led to more profound inflammatory tissue changes which led to the additional complications downstream.
What makes you a good expert for this case?
I am a general urologist and have been in practice for over 17 years. I have a keen interest in Endourology with fellowship training as well as urologic trauma. I work at a high volume tertiary hospital with a busy ER where we treat a multitude of urologic emergencies.
How often do you encounter cases similar to this one in your practice?
While I haven't dealt with this exact complication in the past, I am a high volume urologic surgeon and my radar is always on the lookout for post-operative complications. This case represented a perfect storm because it combined two very routine operations into one, and unfortunately a complication occurred due to unanticipated devascularization of the testicle. A more experienced or cautious urologist would have had a high index of suspicion for complications given the combined surgery with potential for iatrogenic vascular compromise. My modus operandi is to assume every patient has some type of post-operative complication until proven otherwise. I also believe in the surgical tenet: If you don't have complications, it means you don't operate enough."
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