Medicolegal Casebook of a Urologist

1. Medicolegal Casebook of a Urologist Mr Simon Fulford FRCS(urol) Consultant Urologist Department of Urology And Spinal Cord Injury Unit James Cook University Hospital Middlesbrough

2. Introduction • Consultant Urologist since 2001 • Consultant Urologist in Regional Spinal Injury Unit • Female, Neurological, Urodynamic and Reconstructive Urology • Liaison Urology • Bladder cancer • General Urology • (NOT Prostate cancer or stones) • Medico legal practice since 2002 • Initially Personal injury cases • SCI, TBI, Pelvic Fractures • Increasing Medical Negligence work • Mix of Defendant and Claimant and Joint instructions • Approximately 50 reports per year • 50:50 PI and CN Urology

3. Common themes in CN cases • Missed / delayed diagnosis and treatment of cancer or other pathology • Injury to the urinary tract during surgery (Urological and other) • Injury to other structures during Urological surgery • Post operative problems Urology

4. Missed / delayed diagnosis and treatment of cancer or other pathology • Injury to the urinary tract during surgery (Urological and other) • Injury to other structures during Urological surgery • Post operative problems Urology

5. Missed Renal Cancer • 50 year old male • Presented to A and E with visible haematuria and right loin pain • Diagnosed with UTI and ? Stone • Dipstick test and MSU sent. No imaging. Discharged with Antibiotics • MSU – no infection, blood only. GP asked to follow up • Repeat MSU – Normal – reassured • 3/12 later visible haematuria again • Referred to Urologist • MSU, Cytology and Cystoscopy normal IVU “normal” – reassured • 4/12 later visible haematuria and loin pain again – seen in A and E • CT showed large renal tumour with lymph node and lung metasteses Urology

6. Haematuria • Visible haematuria • > 45 – two week wait • < 45 – Routine referral • Non Visible Haematuria • > 60 – two week wait • < 60 – Routine • Detailed history • Examination including PV or DRE • Urine Culture • Urine Cytology • Renal function, clotting, full blood count and PSA • Upper tract imaging • Cystoscopy Urology

7. Loin pain • All loin pain is NOT caused by renal colic (kidney / ureteric stones) • In fact 50% of cases are due to other pathology • PUJ Obstruction • Clot Colic • Musculoskeletal pain • AAA • Renal Colic very rarely causes visible haematuria • 95% of cases of renal colic will have non visible haematuria (But NOT all) • Renal Colic must never be diagnosed without confirmatory imaging - CTU, USS and KUB X ray • Management of renal colic depends on size and position of stone, pain control and signs of secondary infection or renal impairment • All suspected cases need Urological follow up Urology

8. Missed renal cancer • A and E • Breach of Duty – failed to adequately investigate • Failed to appropriately refer to Urology • Failed to communicate with and advise GP appropriately • GP • No breach of duty due to lack of communication from A and E • Urologist • Breach of duty in not requesting USS or CT • Radiologist • Breach of duty in poor execution and reporting of IVU – including not advising of need for USS / CT • Causation • Missed opportunity of curative treatment … (80% chance of five year survival reduced to less than 5%) • Case rapidly settled in favour of Claimant Urology

9. Delay in treatment of bladder cancer • 65 year old female • One year history of intermittent haematuria and LUTS • 2WW referral to Urology • USS – 3cm mass in bladder • Patient was told she had “a polyp” in her bladder and that she needed a cystoscopy • Lost to follow up • Further haematuria – GP re referred • Cystoscopy and TURBT 15/12 after USS – G3T1 TCC with Cis • Radical Cystectomy – G3 T2 TCC, nodes negative Urology

10. Delay in treatment of bladder cancer • Sued first Urologist • Breach of duty • Poor communication – “polyp” rather than “bladder cancer” • Administrative delays • Causation • Progression of cancer from superficial to muscle invasive • Missed opportunity for bladder conservation • Worse prognosis • Case settled in favour of the Claimant Urology

11. Bladder cancer staging and survival Urology

12. Delay in diagnosis of Prostate Cancer • 65 year old man • Referred by GP to Urology with LUTS for six months • PSA 5.0 (ULN 4.0) (patient not informed) • Diagnosis of Benign Prostatic Hyperplasia and Bladder Outflow Obstruction made – • without DRE or flow rate • Started on Tamsulosin, discharged • 12/12 later developed low back pain • PSA now 120, DRE “Hard Craggy Prostate” • Widespread metastatic disease • Hormone deprivation therapy • Died 9/12 later Urology

13. Prostate Cancer staging and survival Urology

14. Delayed diagnosis of Prostate Cancer • Indefensible • Failure to examine the prostate • Failure to address PSA • LUTS • Assessments must include PSA and DRE • Raised PSA • DRE • MRI • Biopsy Urology

15. Testicular torsion • 10-30 years old • Sudden onset testicular pain and swelling +/- Nausea and vomiting • May radiate to groin, abdomen • May have low grade fever, raised inflammatory markers • Urine usually negative for blood cells • Examination findings highly variable • Infarction can occur after six hours – time is critical • DO NOT rely on / wait for USS • DO explore URGENTLY if suspicion • Timings crucial in sorting out BoD Urology

16. Missed testicular torsion case • 16 year old seen in A and E at 11pm with two hour history of severe left testicular and groin pain • See by A and E junior who diagnosed renal colic despite no loin pain, no blood in urine. • Scrotum was not examined despite patient suggesting he had a testicular torsion. • Patient was admitted to Urology ward without informing the Urology team or getting CTKUB – against hospital policy • FY1 on call went to clerk patient at 6 am and immediately diagnosed a torsion • Scrotum explored within thirty minutes but testicle ischaemic and subsequently atrophied • Breach of Duty – inadequate examination and investigation • Causation – loss of opportunity to save testicle • Litigation ongoing but my advice is that this case is not defendable Urology

17. Another missed testicular torsion ? • 49 year old man • Woke at 0630 with testicular pain and scrotal swelling • Rang 111 at 1217, was diagnosed with a torsion and advised to attend A and E asap • Attended A and E 1600 and was referred to Urology • Seen by Urology Spr at 1700, diagnosed with epididymo orchitis (hot, red swollen, tender hemiscrotum, +ve urine dip) • Discharged with antibiotics and plan for outpatient USS • 1/12 USS shows hydrocele, thickened epididymis and no blood flow to testis • 1/12 later had orchidectomy and histology confirmed testicular infarction • Sues alleging missed torsion • Successfully defended on basis that infarction was secondary to infection not torsion and in any event he presented more than eight hours after onset of pain Urology

18. Missed / delayed diagnosis and treatment of cancer or other pathology • Injury to the urinary tract during surgery (Urological and other) • Injury to other structures during Urological surgery • Post operative problems Urology

19. Urology

20. Injury to Urinary Tract Urology

21. Gynaecological and Obstetric injuries • Ureteric injury can occur in several ways • complete occlusion by suture of ligature or clip • Partial occlusion with our without intra or extra peritoneal leakage leading to UVF • Diathermy or heat injuries may only become apparent after a few days • I have had two recent cases of ureteric injury during colorectal surgery • Bladder injuries will usually be noted and repaired • Vesico Vaginal Fistulae • Usually due to inclusion of bladder in vaginal vault suture leading to pressure necrosis and leakage from one week on • Urethro-vaginal fistulae can occur following vaginal surgery • Uretero-Uterine and Utero-vesical can occur following C section Urology

22. Urology

23. Vesico Vaginal Fistluae Urology

24. Urology

25. Gynaecological and Obstetric injuries • Differentiating between fistula sites is important • VVF usually give a continuous leak without voiding • UVF will have continuous leak and regular voiding • Patients may have one or more fistula – important to check before repair • Small fistulae may close with conservative treatment – catheterisation, stenting or nephrostomy • Immediate repair if possible gives good results but unless within first week the tissue s will be oedematous and therefore it is preferable to wait three months • UVF / ureteric obstruction usually require ureteric reimplantation • VVF can be repaired either vaginally or via an abdominal incision • Fistula surgery should only be carried out by experienced surgeons Urology

26. VVF case • 46 year old female • Abdominal Hysterectomy for heavy painful periods (following very brief consultation, no alternative treatment discussed) , “routine three pedicle TAH BSO” • Developed severe abdominal pain and continuous vaginal leakage on day three • CTU shows probable VVF and normal kidneys and ureters • Transferred to Urology and undergoes cystoscopy and EUA finding 4cm VVF • Offered immediate repair or three month trial with catheter • Successful trans abdominal repair 10/7 post hysterectomy • Continent but has ongoing frequency and Urgency, Detrusor Overactivity on Urodynamics • Breach of Duty – options not discussed, inadequate consent, incompetent surgery • Causation – pain and distress, two more operations, Detrusor Overactivity Urology

27. Ureteric injury • 45 year old had hysterectomy and BSO for endometriosis • Straightforward operation although “vascular” • RIF pain radiating to right loin noted from 24hrs but not investigated • Discharged after five days • Readmitted on day 12 due to right loin pain • USS showed hydronephrosis and hydroureter • IVU AFTER A 5 DAY WAIT confirmed obstruction of distal Right ureter • Referred to Urology, Nephrostomy inserted • Ureter reimplanted one month later • Renogram at 18 months showed 35% function and free drainage Urology

28. Urology

29. Ureteric injury • Injury probably occurred during haemostasis ? diathermy as no suture found at reimplantation • Despite no record of steps taken to avoid such injury / check ureter at end of procedure Defence successfully argued this was an acceptable complication given “Vascular” nature of operation, and the fact ureteric injury was included on the consent form (!) • However Claimant succeeded in claim that diagnosis of injury was negligently delayed and that this resulted in pain and suffering and loss of renal function Urology

30. Missed / delayed diagnosis and treatment of cancer or other pathology • Injury to the urinary tract during surgery (Urological and other) • Injury to other structures during Urological surgery • Post operative problems Urology

31. Catheterisation and Urethral Stricture • 29 year old RAF technician underwent emergency laparoscopic appendicectomy, no pre existing lower urinary tract symptoms • Catheterised during procedure but no record of this or catheter removal • Rapidly developed dysuria, urethral bleeding and reduced urinary flow • Referred to Urology 2/12 later and found to have a urethral stricture • Had urethral dilatation under GA and continues to do Intermittent Self Dilatation • Breach of duty – failure to carry out catheterisation with reasonable skill • Causation – urethral trauma causing stricture formation, pain and distress, need for urethral dilatation and intermittent self dilatation, future risk of requiring urethroplasty, limitation to employment with RAF Urology

32. Surgery for Lower Urinary Tract Symptoms • 55 year old man with marked LUTS (hesitancy, poor flow, nocturia) for 12/12 • No flow rate or urethrogram but Urethral stricture diagnosed • Admitted for cystoscopy + ? Urethrotomy • No stricture found but “very high bladder neck” noted • Surgeon proceeded with bladder neck incision and TURP • Flow better but frequency and Urgency and Nocturia no better • Developed Retrograde ejaculation • 10/12 later flow deteriorated and Bladder neck stenosis diagnosed and divided • Breach of duty – Inadequate investigation, no conservative treatment, no alternatives offered, not warned LUTS may persist, not warned re retrograde ejaculation or re operation risk • Case rapidly settled in his favour Urology

33. Urology

34. Urology

35. Urology

36. Urology

37. Ureteric Avulsion • 55 year old man presents with a 10mm stone half way down his ureter • He has persistent pain and is offered ESWL or ureteroscopy and lasertripsy • A guidewire was passed beyond the stone and the ureteroscope advanced over this wire to the stone • Guidewire was removed and laser fibre used to fragment the stone • No second “safety wire was inserted • Stone basket inserted to remove fragments • Following removal of the fragments ureter was seen everted into the bladder • Nephrostomy inserted and patient woken up • Offered ileal interposition or simple nephrectomy – opted for thelattter which was carried out without complication Urology

38. Ureteric Avulsion • Greatly feared but fortunately extremely rare complication • Can and should be avoided by use of second “safety” wire and lasering the stone to “dust” so that no large fragments remain • If safety wire had been present it would have been possible to stent ureter • Had the stone been “dusted” then basket extraction would have been unnecessary • Breach of duty clearly occurred in conduct of procedure • Causation was pain and distress and need for surgery Urology

39. Suprapubic catheter insertion • 63 year old man with LUTS attended Urology OPA and found to be in painless retention • Sent to A and E to be seen by on call Urology team • Urethral catheterisation attempted but not possible • Supra Pubic catheter placed in A and E with LA by locum SHO in Urology • Patient described it as “the most painful experience of my life” and “an assault by stabbing in the abdomen” • Urine drained bladder and patient discharged home 30 minutes later to await Urology OPA • Went home, collapsed, 999, Ambulance to another hospital, peritonitis diagnosed, laparotomy finds SPC to have perforated small bowel • Bowel repaired and SPC re sited • Transferred Urology care to second hospital and subsequently underwent successful TURP Urology

40. Suprapubic catheter insertion • Sued alleging breach of duty during insertion of SPC • I was asked to do screening report and in course of reviewing medical records discovered two notes relating to SPC insertion • Hand written three line note in A and E record – “SPC inserted LA” • Note on hospital EPR with text book description of SPC insertion “two finger breadths above pubis …” retrospectively entered one week after SPC insertion on the day patient contacted PALS at first hospital … • When I subsequently examined patient he showed me site of SPC which was in RIF ! • He also told me Locum SHO has returned to home country and his is one of six cases relating to a two week post at first hospital ! • Case settled in Claimant’s favour Urology

41. Suprapubic catheter insertion Urology

42. Urology

43. Missed / delayed diagnosis and treatment of cancer or other pathology • Injury to the urinary tract during surgery (Urological and other) • Injury to other structures during Urological surgery • Post operative problems Urology

44. Ureteric stent Urology

45. Retained Double J stent • 25 year old man presented with persistent pain due to a 7mm stone in left ureter • Underwent a successful left ureteroscopy and lasertripsy • A stent was placed due to ureteric oedema • The patient was discharged two days later • No plan was made to remove the stent • The patient was not informed it was present • There was no stent register • Patient DNAd follow up at six weeks and was discharged • 6/12 had single episode of haematuria and KUB showed 2cm stone in kidney and 3cm stone in the bladder Urology

46. Urology

47. Retained Ureteric stent • Removal of the stent and two stones required three procedures over a three month period fortunately renal function was preserved • Patient sued Urologist • Breaches of duty • Failure to inform / consent patient re stent • Failure to plan for removal • Failure to maintain stent register • Discharging patient without checking is stent was in place or removed • Case was settled promptly as no defence was possible Urology

48. Conclusions • Urological medico legal practice is alive and well ! • Common themes • Missed / delayed diagnosis • Injury to Urological Organs • Injury to other Organs by Urologists • Post operative problems • Common Breaches of Duty • Failure to appropriately investigate • Failure to appropriately discuss options • Failure to follow clear guidelines • Failure to operate with due care and attention • Failure to ensure appropriate follow up • Poor administration Urology

49. Thank you for your attention Mr Simon Fulford BMI Woodlands Hospital Morton Park Darlington DL2 1PW simonfulford@nhs.net 07855 312901 Urology