Gynecology expert witness discusses a total abdominal hysterectomy that resulted in bilateral ureteral injury

A gynecology expert witness opines on a case of an ovarian cancer patient who suffered a bilateral ureteral injury during a total abdominal hysterectomy with bilateral salpingo-oophorectomy. This case involves a sixty-five-year old female patient with a past medical history of adult baby powder use, rheumatoid arthritis, and systemic lupus erythematosus. The patient presented to her primary care physician complaining of a six month history of pelvic pain. She described the pain as severe and said that it was increasing in severity. The physician performed an ultrasound scan to investigate. The ultrasound revealed a large ovarian mass which the physician suspected to be malignant. This prompted the physician to order blood work for CEA and CA 125 tumor markers. The CEA level returned in the high range of 6.4 and the CA 125 was high at 110. The patient was then referred for surgical intervention and underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy that was reported to be conducted without complication but the patient demonstrated some difficulty post-operatively. The patient’s BUN/Cr continued to rise dramatically and she had a persistent fever with leukocytosis on the subsequent post-operative days. The patient was taken back into surgery after a CT scan of the abdomen showed fluid buildup in the pelvis. Further work-up revealed evidence of ureteral injury during the first resection procedure and the patient required re-implantation of the ureters to avoid permanent nephrostomy tube therapy. Furthermore the patient’s cancer was inadequately staged after her primary resection procedure and required an additional resection of the cervix that was only partially successful due to extensive scarring and fibrosis. The patient had a poor overall prognosis after her care at this institution and the chance of recurrence after her treatment was significant.

Question(s) For Expert Witness

1. Is it within the standard of care to obstruct the ureters during this procedure?

2. Could a more skillful dissection on the original resection procedure have altered this patient's outcome?

Expert Witness Response E-000078

Ureteral injuries can occur without negligence, but they should be recognizable at surgery and repaired at that time. It is a known complication of these types of surgeries however it is the duty of the gyn-oncologist to be aware for the potential of ureteral injury and should have recognized this during the case. This case calls into question not only the skills but also the experience of the gyn-oncologist. How often had he performed this procedure? The patient’s cancer staging should have been performed at the primary surgery. Whether these deviations from the standard of care ultimately affect survival depends on the nature of the cancer and subsequent response to treatment. This is an unfortunate case. It is rare to obstruct both ureters in a case especially with supra-cervical hysterectomy.