Gynecologic Surgery

Introduction

The ureters are muscular tubes that propel urine from the kidneys to the urinary bladder. They originate in the pelvis of the kidney and terminate in the base of the bladder. Each kidney has one ureter.

An ureteral injury is a rare but potentially devastating complication of all major gynecologic operations. The question that arises when such an injury occurs is whether it was the result of improper surgical technique or medical malpractice. There is not just one answer. Much will depend on the particular circumstances of each individual case.

Definitions Relating to Some Types of Gynecologic Surgery

Hysterectomy

Hysterectomy is generally referred to as the removal of the uterus. However, other organs such as ovaries, fallopian tubes and the cervix may be removed as part of the surgery. The three types of hysterectomies are as follows:

• Radical hysterectomy: complete removal of the uterus, cervix, upper vagina, and parametrium. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually removed in this situation.
• Total hysterectomy: Complete removal of the uterus and cervix.
• Subtotal hysterectomy: removal of the uterus, leaving the cervix in situ.

Oophorectomy

In many cases, the surgical removal of the ovaries is performed along with a hysterectomy.

An oophorectomy is the surgical removal of an ovary or ovaries. The removal of an ovary together with a fallopian tube is called a salpingo-oophorectomy or unilateral salpingo-oopherectomy (USO). When both ovaries and both tubes are removed, the procedure is called a bilateral salpingo-oophorectomy (BSO). In many cases, the surgical removal of the ovaries is performed along with a hysterectomy. The surgery is then called a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO).

Ovarian Cystectomy

An ovarian cystectomy is the surgical removal of all or part of the urinary bladder. It may also be used at times to refer to the removal of an ovarian cyst.

Generally, a cystectomy is the surgical removal of all (total) or part of the bladder (partial cystectomy). There are three methods used to perform a cystectomy. The first is the traditional radical cystectomy, which is an open surgery performed manually by creating an incision in the abdomen. The second is a laparoscopic cystectomy, which is performed through thin instruments placed into the abdomen with small incisions while the surgery is viewed on a monitor by the surgeon. The first is a robotic cystectomy, which is similar to the laparoscopic surgery except that a da Vinci robot is used for finer control, better suturing, and a magnified high definition 3D view of the surgical site.

Rectocele or Enterocele Repair

A rectocele occurs when the end of the large intestine (rectum) pushes against and moves the back wall of the vagina.

Rectoceles and enteroceles may develop when the lower pelvic muscles become damaged by labor, childbirth, or a previous pelvic surgery.

An enterocele (small bowel prolapse) occurs when the small bowel presses against and moves the upper wall of the vagina.

Rectoceles and enteroceles may develop when the lower pelvic muscles become damaged by labor, childbirth, or a previous pelvic surgery. The condition may also develop when the muscles are weakened by age.

Cystocele Repair

A cystocele is a condition that occurs when the supportive tissue between a woman’s bladder and vaginal wall weakens and stretches, allowing the bladder to bulge into the vagina. A cystocele may also be called a prolapsed bladder.

Dilation and Curettage (D&C)

During a Dilation and Curettage (D&C) the entrance of a woman’s uterus is expanded or enlarged so that a thin, sharp instrument can scrape or suction away the lining of the uterus and take tissue samples.

D&Cs are commonly performed for the diagnosis of gynecological conditions leading to abnormal uterine bleeding, to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow), to remove the excess uterine lining in women who have conditions such as polycystic ovary syndrome (which cause a prolonged buildup of tissue with no natural period to remove it); to remove tissue in the uterus that may be causing abnormal vaginal bleeding, to remove retained tissue, and as a method of abortion that is now uncommon.

Today, the procedure is routine and considered safe. A D&C is frequently done as an adjunct procedure to a hysteroscopy and/or polypectomy.

Pelvic Anatomy

The pelvic cavity is a body cavity that is bounded by the bones of the pelvis. It primarily contains reproductive organs and the rectum. The organs include the uterus, bowel, bladder and ureters. The uterus is central to both adnexal regions. The rectum and bladder are located posterior and anterior to the adnexal regions. The ureters are located near the ovarian blood supply. They originate in the pelvis of the kidney and terminate in the base of the bladder. Each kidney has one ureter.

Duty of the Surgeon

Regardless of the gynecological procedure being performed, it is the duty of the surgeon to correctly identify the pelvic anatomy and protect these vital structures during the surgery. The surgeon will be held to the standard which an ordinary and reasonably prudent surgery would be held to under similar circumstances. The surgeon will not be held to the standard of a “super-specialist.”

Ureteral Injuries during Gynecologic Surgery

The reported incidence of ureteral injury during gynecologic surgery is relatively low. These injuries, however, do occur in routine as well as complicated surgical cases.

When an iatrogenic ureteral injury (or an injury caused by the surgeon) is attributable to lapses in technique or concentration, this is a surgical error for which the surgeon may be held liable.

Damage to a ureter during a gynecological surgical procedure will most likely be due to the surgeon’s misidentification of the structure. The common issues that arise in such a case are what caused the misidentification and whether it avoidable; whether the surgeon used the accepted intraoperative techniques in performance of the procedure; whether there were appropriate and necessary pre-operative testing and/or consultations; whether there were appropriate intra-operative tests order and/or consultations; and whether the injury to the ureter was recognized during the procedure. Merely because there was a bad result does necessarily mean there was malpractice. Moreover, on the other side, simply saying that an injury to the ureter during a gynecological surgical procedure is a known risk does not exonerate the surgeon from liability where the surgeon failed to use proper technique or failed to recognize the injury intraoperatively.

When an iatrogenic ureteral injury (or an injury caused by the surgeon) is attributable to lapses in technique or concentration, this is a surgical error for which the surgeon may be held liable.

There are occasions, however, where continued dissection will require the surgeon to accept the risk of unavoidable ureteral injury. This may be due to distortion of the pelvic anatomy or as a result of an intraoperative emergency. Such distortion of the pelvic anatomy, with destruction of planes of dissection, can occur due to infection, endometriosis, radiation fibrosis or even cancer. Such complications turn a hysterectomy or adnexal surgery into laborious, difficult and dangerous surgical feats. Where the surgeon needs to continue with the procedure for the safety and well-being of the patient, the surgical goal outweighs the risk of injuring the ureter. Under these conditions, the surgeon must still recognize that the ureter is at risk, and upon completing the procedure, must confirm the integrity, or violation, of the ureter. A failure to recognize a ureter injury intraoperatively can lead to serious morbidity, loss of kidney, and even death.

The Pelvic Anomaly Defense

The usual defense when there is a ureteral injury during a gynecologic surgical procedure is that damage to the ureter is a known risk, and, therefore, the surgeon cannot be found liable. Merely because the surgeon encountered a distortion or anomaly of the pelvic anatomy during the procedure, however, does not give the surgeon a free pass to injure the ureter. It must first be established that that the surgeon took all reasonable steps to identify and protect the ureter in light of the known anomalies.

Simply stating that the ureteral laceration is a “known complication” of pelvic surgery is a self-serving statement that does not excuse inadequate preoperative investigation and intraoperative care to which the patient was entitled. Therefore, a surgical laceration of a ureter during the pelvic dissection without adequate pre-operative and intraoperative investigation and without proper surgical technique is a deviation from accepted practice.

A patient’s history, for example, of previous massive adhesions or tubal infection, should alert a reasonable surgeon that there would be anatomical distortions making the proper identification of the ureters more difficult during dissection. Based on such a history, it would be a departure from accepted medical standards to fail to diagnose pre-operatively the probability that extensive adhesions would be encountered during the surgery and perform the appropriate pre-operative investigations and precautions.

Preoperative Departure from Accepted Medical Practice

A surgeon has a duty to recognize preoperatively, where there is indication by history, sonogram or other preoperative test that there will be anatomical distortions encountered during the surgery, to minimize the risk of injury to the ureters by ordering the appropriate preoperative procedures.

It is well known that the anatomical location of the ureters may be altered because of the pathological processes associated with adnexal masses or complications such as a matted loop of bowel. Pre-operative indications of these distortions should indicate that the ureters may be involved and incorporated in the mass making their identification difficult during the surgery.

With such a pre-operative profile, the accepted practice is to order an intravenous pyelogram (IVP) to help identify the course of the ureters preoperatively. It is also accepted practice to call for a pre-operative urologic consultation for the purpose of catheterizing the ureters. With use of catheters, the surgeon can feel the ureters because there is now a semi-rigid structure and a palpable object in the ureters making it easier to identify and protect the ureters during dissection.

Intraoperative Departure from Accepted Surgical Practice

It is a deviation from accepted surgical practice to fail to identify the ureters intraoperatively during the pelvic dissection that results in ligation or transection of a ureter. The generally accepted surgical practice is to locate and identify the ureters intraoperatively by visual and palpable confirmation.

When the surgeon encounters a difficult surgical field due to the extensive adhesions or other distortions that makes visual and palpable confirmation difficult, the accepted surgical practice is to stop the pelvic dissection to call for an intraoperative urologic consult and intraoperative ureteral catheterization to catheterize the ureters in order to assist in appropriately identifying the location of the ureters and provide for their adequate protection.

Repair of Ureteral Injury Intraoperatively

When there is a ureteral injury a stent will be placed in the ureter, from the renal pelvis to the bladder, and then the ureteral hole will be repaired with a few chromic sutures. Using cystoscopy, the presence of the catheter will be confirmed in the bladder, for eventual stent removal. If the stent fails, the strictured segment may have to be surgically removed, and the proximal end of the ureter implanted directly into the bladder.

Conclusion

Of course, a preoperative IVP or pre- or intraoperative placement of ureteral stents will not prevent all ureteral injuries, but will certainly assist in their identification and visualization of the ureters and will minimize the incidence ureteral injuries.

The complications associated with a severed ureter are severe. It can result in stricture of the ureter, recurrent urinary obstruction, hydronephrosis, kidney damage, kidney loss, and even death.

Therefore, a surgeon must take every reasonable precaution to minimize the risk of injury to the ureters during a gynecological surgery. The failure to do so is a surgical error and may expose the surgeon to liability for medical malpractice.

If you or a loved one has sustained a ureteral injury during the performance of a gynecological surgery you should immediately speak to a experienced New York medical malpractice attorney to protect your rights and review your potential claim.