Client is a 74 years old with erectile dysfunction and dysuria. He was diagnosed with BPH unresponsive to Alfuzosin. Also a h/o prostatitis.
Cystoscopy showed severe coaptation of lateral lobes of prostate with mild enlargement of median lobe. Qmax 7.21 with very elongated uroflow showing complete obstruction. On 2-13-24, he had a Aquablation. Postoperatively, he lost control of his bladder sphincter & developed stress & urge incontinence which did not improve with OAB medications.
Repeat cystoscopy revealed the following: an aggressive Aquablation with the distal limits of that resection extending through the apical prostate and verumontanum. The prostatic fossa is open the bladder neck is open.
The patient was referred to another physician for possible bladder reconstruction including about a male sling to provide some passive support to the urethra and an artificial urinary sphincter. The client has been hesitant to move forward with additional procedures because of his negative experience with Aquablation.
Was there operative negligence in performing the Aquablation? Procedure report attached.
Files:
Q: What was the prostate volume by imaging?
A: Prior to the Aquablation, there is a note that the Prostate is more than 50 grams
Q: Did the patient have elevated post void residuals preoperatively?
A: The only mention in the preop HPI is "patient voided more than 134". (Not specifically post void residuals) along with failed medical & injection treatment for ED.
Q: was there any evidence of UI prior to procedure, what was IPSS for pt?
A: NO UI preoperatively. The IPSS was 9 QOL 6 several months post Aquablation.
Q: It states that the procedure report is attached, but I do not see any files.
A: I could only attach a picture of the Op report.
Do you believe there might have been medical error?
There is the potential to develop post-procedural urinary incontinence after Aquablation (or any other similar treatment modality for BPH). This is a standard part of the preoperative counseling. Additional information about the prostate size via imaging would be helpful in assessing whether Aquablation was an appropriate choice.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Avoiding the sphincteric mechanism and verumontanum is a goal of the procedure, but this cannot be achieved 100% of the time. There are treatment options for this patient's post-procedural incontinence, although they are primarily surgical.
What makes you a good expert for this case?
I perform the largest volume of male anti-incontinence surgeries in Brooklyn, NY.
How often do you encounter cases similar to this one in your practice?
I have seen similar situations after TURPs, Aquablation, robotic simple prostatectomy, and of course radical prostatectomy. This is not a rare event.
Do you believe there might have been medical error?
Yes, if the aquablation went beyond the verumontanum , there is likely damage to the external sphincter which will then require reconstructive surgery to improve the stress incontinence.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, stress incontinence is certainly caused by the aquablation procedure.
What makes you a good expert for this case?
I am a fellowship trained, board-certified urologist with several years of experience who treats BPH medically and surgically on a daily basis
How often do you encounter cases similar to this one in your practice?
this certainly is a case that I have been several times in my career so far.
Do you believe there might have been medical error?
Bad planning led to the sphincter injury
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Same explanation The treatment ablated the sphincter as well as the prostate
What makes you a good expert for this case?
Experience in Aquablation and BpH makes me good for this Case
How often do you encounter cases similar to this one in your practice?
Never in my hands This is negligent and they should settle He will need a sphincter to overcome the problem
Do you believe there might have been medical error?
The fact that the bladder neck and verumontanum were ablated notes that the procedure was performed incorrectly. Both should be preserved to maintain continence and ejaculation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
These anatomic landmarks should not be disturbed. This is the reason the patient has stress incontinence.
What makes you a good expert for this case?
I perform at least 30 BPH surgeries annually. I am well aware of the need to maintain these anatomical landmarks to preserve continence regardless of the procedure. This has been the way since the old days of TURP.
How often do you encounter cases similar to this one in your practice?
Rarely. That’s because I don’t like aquablation. It’s an operation with no surgeon control.
Do you believe there might have been medical error?
I am not an AquaAblation expert but with any Trans urethral surgical treatment, if the sphincter is damaged then the resection had come out too distal so an error by the surgeon or by the device would result in this injury
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above any damage to the sphincter with any modality can cause stress incontinence. Urge incontinence is generally a temporary side effect of a trans urethral procedure. In AquaAblation the surgeon by ultrasound maps out the obstructive tissue and that zone is the treatment area. If the mapped out adenoma is too distal then the AquaAblation will destroy tissue too close or at the external sphincter itself resulting in stress incontinence. Was the surgeon too aggressive or did the AquaAblation treat too distally beyond what was mapped by the surgeon? One would need to inspect the operative ultrasound to determine the zone of treatment.
What makes you a good expert for this case?
Although mostly retired now, I was a Board certified Urologist for 35 years. I am not an expert in AquaAblation so that may disqualify me for advice but my answer reflects general injury to the external sphincter.
How often do you encounter cases similar to this one in your practice?
In my practice I never encountered an AquaAblation injury but have seen a number of sphincter injuries from TURP,Laser PVP, microwave treatment for BPH. Any damage to the sphincter mechanism can result in stress incontinence whether resected, cauterized, on incised. As a side, I would not personally do a male sling but would offer an AUS (artificial urinary sphincter) assuming he has significant stress incontinence.
Do you believe there might have been medical error?
Destruction of the veru and the sphincter is due to the urologist not correctly mapping the distal extent of the urethra. This must be done by TRUS and by cystoscopy and they must match and be confirmed before proceeding. If there is a mismatch, then you this type of result which is a catastrophe. The bigger question is how much experience the urologist has with Aqua prior to this case. In addition, there was also likely over aggressive ablation near the veru anyway due to mismeasuring the landmarks.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the veru and/or the sphincter are injured then UI will directly result.
What makes you a good expert for this case?
Attention to detail of the case Knowledge of the anatomy and procedure Confidence in evidence based outcomes.
How often do you encounter cases similar to this one in your practice?
I had partners who performed Aqua and observed their results which is why I chose to not perform it. That should tell you everything.
Do you believe there might have been medical error?
The post ablation cystoscopy reveals that the external urinary sphincter as well as verumontanum were included and ablated within the surgical field. This indicates the surgeon did not appropriately map the prostatic anatomy to avoid critical structures including verumontanum and external urinary sphincter
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the ablation field damaged critical structures verumontanum as well as external urinary sphincter, this would cause post-op stress urinary incontinence. It is well known that stress as well as urge urinary incontinence can be potential side effects after most transurethral ablative prostate surgeries. While this is a well-known side effect of all transurethral prostate surgeries, the risk is minimized by expert surgeon that can recognize critical anatomy and avoid inadvertent injury to these structures during surgery
What makes you a good expert for this case?
I am a high volume endourologic surgeon with expertise in BPH surgery as well as kidney stone surgery. I perform at minimum 100 TURP and other BPH MIST surgeries at an outpatient ambulatory surgery practice in a busy urban area
How often do you encounter cases similar to this one in your practice?
Earlier in my career, I had some patients who experienced stress urinary incontinence after TURP, after adjusting my technique and becoming more expert at this operation, I no longer see this complication
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