Kinked Ureter and Kidney Failure From Hysterectomy Procedure

This case involves a 40-year-old woman who presented for an elective laparotomy with lysis of adhesions, enterolysis, and abdominal hysterectomy with bilateral salpingo oophorectomy. During surgery, the Foley catheter was removed because the patient did not pass urine for some time and a cytoscopy was performed. The bladder edges had prominent blood vessels and it was slightly hydrodistended. There was rapid flow from the patient’s left orifice. The right orifice had delayed function and at this point the attention was turned back to the abdominal cavity. The ureter was felt to be kinked under a suture. The suture was released, and there was good flow through the ureter. The surgery was completed without further complication and the patient was discharged. On post-op day 9, patient presented to the ER with complaints of an increase in abdominal pain, fever, and urinary frequency. The patient was diagnosed with right hydroureteronephrosis and acute kidney failure.

Question(s) For Expert Witness

1. Was the care rendered to the kinked ureter within the standard of care?

2. Was any additional testing/follow-up required to determine the delayed function of the right orifice?

Expert Witness Response E-006011

During a hysterectomy procedure, a ureteral dissection is not routinely performed unless concern arises about a potential or actual injury to a ureter. Dissection presents significant risk, since the ureters course under the peritoneum and through a highly vascularized region that can easily be injured, resulting in major bleeding. In this case it seems as if the sutures were placed to stop some bleeding and the surgeon did not realize that the ureters were obstructed until some time later. The patients BUN/Cr should be followed closely after surgery and if it wasn't recognized then after abnormal lab values, that now becomes a failure to diagnose the more complicated issue of acute renal failure.