Allegation
Despite plaintiff’s expert testimony, the defense argued an undesirable outcome does not equate to a breach of the standard of care. The jury agreed and returned a verdict in favor of the defendant urologist.
The Case
The patient, a 53 YOAAM (6'3", 230lbs.), had a history of testicular pain, primarily associated with intercourse. His medical history also included erectile difficulties, prostate infection, fungal infection in the perirectal region, prostatitis complicated by epididymoorchitis, and microhematuria. The defendant urologist had treated the patient for 11 years.
The patient presented to the defendant urologist, having experienced some bleeding and increased discomfort following intercourse. Examination revealed redundant prepuce and adhesions between the glans and the foreskin bilaterally. The defendant urologist was unable to retract the foreskin manually. He recommended circumcision, and discussed the alternatives as well as the material operative risks with the patient. The discussion did not include the risk of too much skin being removed. The patient was asked to discuss the risks and alternatives with his wife and advise of his decision. Ultimately, the patient scheduled surgery for later that month.
The circumcision was uneventful. At the start of the procedure, the defendant urologist marked the circumference of the foreskin at the level of the corona and pushed back on the penoscrotal junction to determine skin removal; however, these steps were not documented. He started retraction of the foreskin, lysing the adhesions between the glans and foreskin. After lysis of the adhesions, the defendant urologist utilized a dorsal and ventral slit back to the marked area; each half of the foreskin was then removed. The pathology report indicated a 6-cm circumference by 3-cm length of skin was removed. The procedure was uncomplicated, and the patient was noted to be healing well at each follow-up visit.
Three months after the procedure, the patient presented to a different urologist for evaluation. The examination of the left side of the glans revealed a small area of the shaft skin adhered to the corona. The patient was diagnosed with "turkey neck/penoscrotal webbing" and was referred to another urologist for revision surgery. During the revision surgery, the urologist excised redundant scrotal skin. The surgery was uncomplicated. A later follow-up with this physician found the patient to be doing well with no problems as a result of the circumcision or subsequent revision.
Following the surgical revision, the patient pursued a claim against the defendant urologist alleging negligent performance of the circumcision and failure to provide proper informed consent. The plaintiff’s first expert witness stated that based on the result, the defendant urologist failed to properly perform the circumcision. The expert alleged that the defendant improperly manipulated the skin when estimating the amount needed to be left before making the incisions. This improper manipulation led to too much skin being removed and created a significant iatrogenic penoscrotal web that interfered with normal sexual function and required corrective surgery.
The plaintiff’s expert was not able to state any specific act or omission that resulted in a breach of the standard of care. He was critical of the informed consent, claiming the discussion must include the amount of skin to be removed as well as problems if too much skin is removed. However, the expert does not inform his patients of this risk; he would not discuss the risk of penoscrotal webbing when obtaining consent from his patients.
The plaintiff’s second expert witness stated the defendant urologist failed to pull the penis to a full erection, as required by the standard of care. Further, the defendant urologist did not flip the penis over and look at the ventral side, which is more important regarding measurement. The defendant’s method resulted in too much shaft skin being removed and pulled hair-bearing scrotal skin onto the shaft of the penis, creating a significant iatrogenic penoscrotal web.
The defendant’s expert witnesses stated the circumcision was medically indicated and performed with appropriate technique. The correct landmarks were used when performing the circumcision, and the removal of too much skin does not, in and of itself, indicate a breach of the standard of care. The witnesses further testified that the only way to be certain if the amount of skin removed is too little or too much is to perform an artificial erection with the patient on the operating table; however, this is not part of the standard circumcision procedure. The defendant’s experts found the informed consent met the standard of care, and stated that physicians are not required to include the risk of removing too much skin.
Resolution
At trial, the jury returned a verdict in favor of the defense after one hour of deliberation.
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