When seven surgeries equal one lawsuit

September 13, 2019

Multiple gynecologic surgeries led to legal action with a surprising outcome.

Facts

A 37-year-old G6P5015 with irregular menses and some right lower quadrant pain presented to her gynecologist for her annual examination. The patient’s examination was normal as was pelvic ultrasound she had approximately 2 months before this appointment. The plan was to obtain another pelvic ultrasound and, if negative, place the patient on oral contraceptives for 2 months. No medical therapy or follow-up was documented. 

The patient’s past medical history was significant for four prior laparoscopies: one for a possible ectopic pregnancy (not confirmed, with decreasing quantitative hCG levels); one for sterilization, with a normal pelvis documented; and two for pelvic pain, one demonstrating a “window” in the posterior broad ligament. Also, the patient had a history of fibromyalgia, anxiety, and depression, which required treatment with three different psychotropic medications. She saw her psychiatrist monthly.

Eighteen months later, the patient was seen for another “annual” examination. She had complaints of heavy vaginal bleeding. The examination revealed a “retroverted uterus, of top-normal size, descending to 1 cm above the introitus.” A thinning rectovaginal septum was noted. The following plan was documented, “Schedule vaginal hysterectomy. Risks and benefits have been reviewed and these have been discussed over the past year-and-a-half since tubal ligation. These symptoms are unremitting to conservative medical modalities. The patient wishes to proceed with surgical intervention.” No documented examinations or discussions since the previous examination, 18 months earlier, were noted. The patient was referred to her psychiatrist for evaluation prior to surgery. 

One month later, the patient underwent a total vaginal hysterectomy with removal of Hulka clips. Pathology revealed a 112-g uterus with proliferative endometrium, no adenomyosis or myomas, chronic endocervicitis, and the Hulka clips. Two weeks later the woman was admitted for cuff cellulitis, which was treated with antibiotics. One week after this second admission, she was seen in the physician’s office with persistent pain and discomfort. Computed tomography (CT) revealed a
5 x 7 cm tubular mass in the left adnexa, with a differential diagnosis of a lymphocele, tuboovarian abscess, or cystic mass of left ovary. Two weeks later the patient underwent laparoscopic adhesiolysis of omental adhesions covering the left ovary and bilateral salpingo-oophorectomy (BSO). Pathology revealed only one tube, which was normal, with normal ovaries bilaterally, one with a simple cyst. The patient was placed on oral estrogen replacement.

A month after the laparoscopy (2 months after the hysterectomy), the woman was seen by her psychiatrist and diagnosed with enhanced anxiety and post-traumatic stress disorder (PTSD). A fourth psychotropic medication was added, as she continued to see her psychiatrist on a monthly basis. 

Nine months after the hysterectomy and 8 months after the BSO the patient was seen for complaints of intermittent stress urinary incontinence for 2 months, with pressure in the vagina. Examination revealed a thin rectovaginal septum and a probable cystocele. She was scheduled for surgery, with her preoperative history documenting “…progressive debilitating loss of urine, minimal valsalva, unable to handle daily activities…” The documented consent discussion in the office consisted of, “Risk & benefit ready.” Three weeks later the patient underwent a cystourethropexy and a posterior colporrhaphy, complicated by a 1200-mL blood loss requiring transfusion. She was discharged with an in-dwelling catheter, which was removed 1 week later with a postvoid residual (PVR) less than 100 mL. She had a mildly odiferous vaginal discharge that was treated with metronidazole vaginal gel. 

The patient was seen in the emergency department (ED) 1 week after the catheter was removed, complaining of bladder pain and abdominal distension. She was found to have acute urinary retention and an indwelling Foley catheter was placed. Three days after the ED visit, the woman was seen by her gynecologist, who noted that a urine culture obtained in the ED revealed Klebsiella pneumoniae > 1000,000 col/mL. The patient was treated with nitrofurantoin. Because she had a PVR of 140 mL, a catheter was reinserted; a CT and ultrasound also were ordered. The CT revealed a pelvic abscess or hematoma. The ultrasound revealed a seroma, with no evidence of an abscess. The patient was referred to a urologist for further evaluation. 

One week later, the urologist evaluated the patient and diagnosed urinary retention, chronic abdominal distention, and depression. An intravenous pyelogram (IVP) was normal without significant PVR. The catheter was removed, and the patient was instructed in self-catheterization, which she performed twice a day. Three weeks after the initial appointment with the urologist, she underwent cystourethroscopy, which found significant residual urine, no sutures visualized in the bladder, and both ureteric orifices seen. She then underwent complex urodynamics, which showed a PVR of 500 mL; the
diagnosis was primary vesical neck contracture and bladder outlet obstruction. One week later, the patient underwent cystoscopy and urethral dilatation. Ten days after that, she was seen in the ED with acute urinary retention. Of note, during her monthly appointment with her psychiatrist, the patient expressed anger with her gynecologist. She continued with self-catheterization. One month after the urethral dilatation, the patient underwent cystoscopy, urethrolysis and urethral dilatation in the operating room, during which the urethra was noted to be elevated well beyond the horizontal and in close apposition to the pubic bone. 

Ten days after her most recent surgery, the patient was again seen in the ED with acute urinary retention (PVR = 1000 mL). A urine culture revealed Klebsiella pneumoniae > 100,000 col/mL, which was treated with levofloxacin. The patient continued to have urinary retention that was unresponsive to additional dilatation. Seven months after the original cystourethropexy, she underwent an open revision of the suspension by the urologist, but her urinary retention persisted and she required ongoing self-catheterization. 

The patient then developed chronic constipation and was referred to a gastroenterologist, who found decreased innervation to the pelvic area, causing urinary retention, obstipation, and fecal impaction. It was postulated that the absent sphincter tone could be secondary to the patient’s psychotropic medications. 

Allegations

The patient sued her gynecologist for performing unnecessary surgery (the hysterectomy), improperly performed surgery (the cystourethropexy), and subsequent complications that required six additional surgeries, with resultant unrelenting urinary retention, obstipation, and PTSD. 

Trial

At trial, the plaintiff’s expert, an academic urogynecologist, testified that hysterectomy was performed without an adequate trial of medical therapy, supported by the lack of significant pathologic findings. Complications from the hysterectomy led to a second surgery, which resulted in the patient, at a relatively young age, requiring long-term hormonal therapy. In addition, the cystourethropexy was performed without an appropriate evaluation or trial of medical therapy. He testified that the preoperative counseling and informed consent were inadequate. He opined that the procedure performed had largely been replaced by less invasive procedures, which have fewer complications. The cystourethropexy was improperly performed with the urethra elevated too high, resulting in persistent urinary retention, unresponsive to six surgical procedures. Further, the were no documented symptoms to justify the posterior colporrhaphy. As a result of these unnecessary procedures, the patient had refractory urinary retention and obstipation. A psychiatrist for the plaintiff testified that, although the patient had preexisting depression and anxiety, her PTSD was directly related to or significantly exacerbated by the complications and multiple surgeries without relief of her symptoms. Further, surgery should be approached cautiously in all patients, but particularly in those with significant psychiatric symptoms, requiring frequent visits and multiple medications. 

The defense’s expert, a rural gynecologist, testified that the numerous surgeries were the result of over-distention following surgery. He could not cite any history to support a diagnosis of stress urinary incontinence. He stated that the patient had a normally functioning bladder with an outlet obstruction. He could not reference any history supporting performance of the posterior colporrhaphy. 

The defendant stated that he never performs a procedure based on one report of a problem. He was then forced to admit that he performed a hysterectomy based upon only one office visit. He also could not explain his note that he had 1½ years of discussions with the patient regarding the problems, nor the lack of any written documentation. He further admitted that his admission history and physical for the bladder surgery were done purely from memory, based on his examination
3 weeks prior. He could not cite any documentation of symptoms justifying the posterior colporrhaphy.

Verdict

Ultimately, the jury rendered a verdict for the defendant. Following the trial, the patient filed for bankruptcy.

Analysis and Learning Points

The gynecologist was very fortunate to receive a favorable verdict. The case demonstrates the fact that most physicians are held in high regard and juries tend to give them the benefit of the doubt. As a result, most cases are found in favor of the defendant physician, occasionally even with overwhelming evidence against them. One must be cautioned that the jurisdiction, or location, of the trial can have a tremendous impact on the verdict. Even with the same facts, some jurisdictions are more favorable for physicians than others.

However, this case demonstrates several opportunities for learning:

  • Surgical procedures should be considered only after adequate evaluation and treatment with medical therapy or less invasive procedures.

  • Gynecologists should remain abreast of currently available procedures, particularly when less invasive procedures are available. In this case, midurethral slings have replaced open cystourethropexy, except in unique cases. If a patient is a candidate for a less invasive procedure that the physician does not perform, he or she should consider referring the patient to a surgeon with the expertise. 

  • Repair of asymptomatic vaginal relaxation, or in this case an asymptomatic thin rectovaginal septum, is not recommended.

  • Informed consent was lacking, or at least appropriate documentation was lacking. The actual informed consent document is intended to memorialize the culmination of discussions between the patient and her physician, providing the patient enough information to make an informed decision about her care and treatment. In general, such documented discussions should address: 1) the diagnosis; 2) the planned procedure or treatment; 3) alternatives to the procedure, including medical therapy and even doing nothing; and 4) the substantial complications that could result from the surgery.

  • Patients with underlying psychiatric conditions, particularly those requiring multiple medications and chronic psychiatric care, require special attention when contemplating major surgical procedures. It may be prudent to have the patient seen by her psychiatrist or psychologist prior to surgery, and to assess any post-surgical changes in psychiatric status.

  • A malpractice suit may be a patient’s only way to pay the medical bills resulting from complications, some of which can be overwhelming. This particular patient had seven surgical procedures following the vaginal hysterectomy. With a defense judgment, the patient and her family had no option but to declare bankruptcy. As physicians, we must be sensitive to the impact our actions and recommendations have on a patient’s life.
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