Commentary:
Although the patient experienced a known complication and a difficult post-op course, the jury returned a defense verdict in favor of both physicians—due in part to clear and detailed documentation and a calm demeanor when testifying.
The Case:
The patient, a 34 YOWF (5’6”, 246 lbs.), saw the primary defendant ob-gyn physician for continuing complaints of abdominal and back pain, fatigue, and blood in the urine. The patient’s history included spinal fusion, cholecystectomy, HTN, endometriosis, dyspareunia, pelvic pain, dysmenorrhea, hypothyroidism, depression, anxiety, and smoking. Ultimately, the diagnosis was an 11 cm symptomatic leiomyoma. After discussing various treatment options, including continued observation and the risks and benefits of each treatment, the patient opted for robotic surgery.
Several weeks later, the primary defendant ob-gyn and his partner (uro-gynecologist), also a defendant, performed a total robotic hysterectomy. The primary defendant ob-gyn encountered multiple large bowel adhesions and took them out. The bladder was dissected off the lower uterine wall. As the procedure progressed, the defendant ob-gyn physician determined the uterus was too large to remove vaginally, so a morcellator was used to complete the surgery.
The primary defendant ob-gyn performed a diagnostic cystoscopy, and a small area appeared abraded either from the initial cystoscope insertion or blanched from the cautery. The bladder, however, appeared intact and there were no rents. The two physicians visualized and discussed the area in question. They agreed the abrasion was inconsequential. An indwelling Foley catheter was placed. The pathology report was benign uterine tissue consistent with leiomyoma.
At the first post-operative visit, the patient indicated she had some abdominal pain but was otherwise healing well. The patient’s Foley catheter was removed, and a urinalysis revealed a UTI. The patient was prescribed Cipro®. Four weeks later, the patient returned for her second post-op visit. She reported feeling much better but still had bladder spasms and a foul vaginal odor. Metronidazole was ordered for bacterial vaginosis. A urine culture revealed enterococcus faecalis, and the physician ordered fluconazole and ampicillin for acute cystitis.
At 10 weeks post-op, the patient’s sister called describing the patient’s bladder issues following the hysterectomy. The patient was still having dysuria, frequency, and inability to completely empty her bladder. Cipro was ordered after rechecking the previous urine culture. The patient, however, had an allergic reaction to Cipro, and the medication was stopped when the urinalysis came back clear.
Two days later, the patient saw the defendant ob-gyn’s APRN with complaints of pain, dysuria, frequency, and bloating. She appeared acutely ill with abdominal tenderness. An ultrasound revealed an 18 mm x 11 mm solid bladder mass and a complex cyst in the cul-de-sac measuring 7.7 cm x 5 cm. A urology referral was made; the patient did not return to the defendant ob-gyn.
The urologist’s initial diagnosis was made by cystoscopy and a suspected neoplasm was biopsied. Pathology reported a papillary structure consistent with the fimbriated portions of the fallopian tubes. A retained suture was found in the bladder and removed. The patient was taken to surgery for an exploratory laparotomy, during which the urologist performed a release of adhesions, removal of a portion of the fallopian tube found in the bladder, and bilateral salpingectomy. She subsequently developed post-operative abscesses requiring treatment and drainage.
Six months post-op, the patient returned to the urologist’s office with complaints of progressively worsening mixed incontinence, urinary urgency, and leakage. Anti-cholinergic medication was prescribed, but due to cost, the patient did not complete the treatment. Physical therapy was prescribed for pelvic floor strengthening; she completed four visits and did not return. Several months later, a pain management referral for chronic pelvic pain was made. The patient had seven visits over the following seven months. In subsequent establishment of care with a new primary care physician, the patient did not mention bladder issues or pain in her history.
The plaintiff alleges the defendant ob-gyn told her he “nicked” her bladder during surgery, thus requiring a Foley to be inserted. The defendant ob-gyn denied making this statement and testified the Foley catheter was done for bladder rest, not as a result of any bladder injury. The plaintiff alleged continued pelvic pain, urinary incontinence, and emotional distress.
The plaintiff’s expert stated the defendant ob-gyn and defendant uro-gynecologist breached the standard of care when they failed to recognize and timely notify a consultant to treat the bladder injury during the hysterectomy. The expert testified that further investigation should have been performed using imaging during cystoscopy to simultaneously view the bladder with the laparoscope and the cystoscope. The plaintiff’s expert testimony at deposition and trial were inconsistent, and the expert conceded that bladder injury is a recognized surgical complication.
The defense expert testified that the standard of care was met and the care was reasonable. Thermal energy injury can occur without any negligence by a surgeon. Multiple post-op bladder infections and the inflammatory healing process may be contributory factors to the patient’s symptoms. The defense expert further stated it is unlikely that an injury to the patient’s bladder was the cause of her alleged incontinence and pain.
The defendants’ documentation was clear, detailed, and supported the care and decision-making. Both defendants testified in a calm and confident manner, and educated the jury in the process.
The jury deliberated for less than an hour and delivered a defense verdict.
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