Wisconsin – Gynecology – Cystotomy Repair During Hysterectomy Results In Anuria

On 1/15/2008, a patient presented to a gynecologist for a pelvic ultrasound and consult.  She had been referred to the gynecologist by her nurse practitioner for evaluation for a pelvic mass and pain with intercourse.  The ultrasound revealed a 6 cm fibroid.  The gynecologist discussed treatment options with the patient, who elected to undergo a total abdominal hysterectomy and left salpingo-oophorectomy.  The procedures were scheduled for 2/6/2008, to be performed by the gynecologist.

On 2/4/2008, the patient presented to the gynecologist for a pre-operative history and physical.  She had a history of a known fibroid and resultant heavy periods with anemia.  The gynecologist discussed with the patient the options and she chose to proceed with total abdominal hysterectomy and left salpingo-oophorectomy.  The patient signed the informed consent form on that date, authorizing the gynecologist to perform the hysterectomy and left salpingo-oophorectomy.

On 2/6/2008, the patient presented to the gynecologist for a total abdominal hysterectomy and left salpingo-oophorectomy.  The gynecologist’s operative report reflects that during the hysterectomy portion of the surgery, a “small incidental cystotomy” occurred on the patient’s right side.  The gynecologist repaired the injury with “two layers of 2-0 Chromic in the standard fashion.”  The surgery ended at approximately 10:59 a.m. and the patient was transferred to the postanesthesia care unit.

At 12:05 p.m., that same day, nursing notes reflect that the gynecologist was informed of decreased urine output.  He ordered that the I.V. fluid be changed to Lactated Ringer’s solution.

At 4:50 p.m., nursing notes reflect that the patient had no urine output and a bladder scanned revealed 11 ml of fluid in the patient’s bladder.  The patient reported feeling abdominal pressure.  The gynecologist was notified of the same and gave an gave an order that 500 ml of IV fluid bolus be given.

At 5:35 p.m., nursing notes reflect that the 500 ml bolus was complete and that the patient continued to report pressure but that it did feel better.  At 6:00 p.m., the nurse notified the gynecologist of the patient’s report of abdominal pressure feeling better.

At 8:10 p.m., the gynecologist was advised that the patient had no urine output despite fluid intake of 1440 ml.

At 9:10 p.m. the gynecologist ordered Lasix (a diuretic) for the patient.

At 10:15 p.m., the gynecologist advised that the patient still had no urine output.  His plan was to “watch longer.”

At 10:40 p.m. the gynecologist advised that the patient had no urine output.  He informed the nurse he would be in to evaluate the patient.

At 10:55 p.m., the gynecologist performed an ultrasound on the patient.  The results were not noted in the patient’s medical chart.

At 11:10 p.m., the gynecologist ordered a STAT CT of the abdomen and pelvis as well as CBC, BUN, and creatinine tests.

At 11:50 p.m. the gynecologist was advised of the lab results, which included an elevated creatinine level of 2.1 mg/DL.

On 2/7/2008, at 12:30 a.m. the patient was seen by a urologist for evaluation of anuria.  He noted that her creatinine level was 2.1mg/DL and that the CT scan showed uptake of the contrast by the kidneys, but no excretion of the contrast into the collecting systems.  He recommended an abdominal exploration with ureterolysis to remove the obstruction, believed to be a stitch, and placement of ureteral stents.  The procedure was schedule to be performed emergently due to incipient renal failure.

At 1:35 a.m., that same day, the urologist began surgery to correct the bilateral ureteral obstruction.  Intraoperatively, the urologist inspected the patient’s bladder and noted that the trigone was “puckered up by the cystotomy stitch.”  He removed the “cystotomy stitches and prior repair sutures” and noted that the injury to the trigone was just distal to the right ureteral orifice and extended past the left ureteral orifice so that the cystotomy ended just proximal to the left ureteral orifice.  After removing all the stitches, the urologist was able to identify the ureters and placed indwelling ureteral catheters in both ureters.  He noted that the patient was then observed to be “making excelling amount of urine, consistent with release of obstruction.”

In performing the hysterectomy on 2/6/2008, the gynecologist failed to properly place the sutures in the trigone, failed to recognize that the stitches were obstructing both ureters and the extent of damage during surgery, and failed to call a urologist for assistance during the surgery to repair the problem.

The Board ordered that the gynecologist be reprimanded, complete the American Urogynecologic Society Review seminar, and pay the costs of the proceeding.

State: Wisconsin

Date: March 2013

Specialty: Gynecology, Urology

Symptom: Urinary Problems, Gynecological Symptoms

Diagnosis: Post-operative/Operative Complication, Gynecological Disease

Medical Error: Procedural error, Diagnostic error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

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