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Ureteric damage

01 November 2003

Mrs K, a mother of six, attended a gynaecology clinic complaining of persistent menorrhagia. After a normal diagnostic D&C she was listed for a total abdominal hysterectomy. The surgery was performed by Dr G, a gynaecology registrar, through a suprapubic transverse skin incision.

Dr G’s operation notes reveal that there was a bulky uterus and difficulty achieving haemostasis at the right vaginal angle, which was eventually secured with sutures. Dr G recorded that the ureters were palpated throughout the procedure and kept clear of the operative field.

Blood loss was 1500ml and Mrs K received four units of blood postoperatively.

At one point Mr M, consultant gynaecologist, was asked to advise on the bleeding, but by this time it had settled. No notes were kept of Mr M’s involvement in the operation. It is assumed his input was brief and limited to a look at the operative field to satisfy himself that haemostasis had occurred.

The next day, Mrs K was seen by Dr G. She had passed about 300ml of urine. On the third postoperative day Mrs K spiked a fever and suffered severe right loin pain with accompanying tenderness. She was treated for a suspected UTI with cephradine.

Over the next four days Mrs K suffered bouts of fever and continuing right-flank pain. She was treated with analgesia and the antibiotics were continued. Dr G eventually requested an opinion from Mr P, consultant gynaecologist, who suspected ureteric pathology and requested an intravenous urogram. This showed a right hydronephrosis, with ureteric trauma the likely cause.

Mrs K was transferred to the care of a urologist where she had a nephrostomy and re-implantation of the right ureter, operative trauma being confirmed as the cause of the obstruction.

Mrs K made a full recovery from both operations, but suffered recurrent bouts of right sided pyelonephritis. Her renal function was normal.

A claim was brought against Dr G, Mr M and Mr P, alleging multiple breaches of duty of care.

Expert opinion

Expert gynaecological opinion held that the surgical technique was satisfactory.

There was criticism of the immediate postoperative care, in that the difficulties experienced during surgery should have led Dr G to institute continuous bladder drainage, given that there was a risk of ureteric trauma. The four-day delay in the diagnosis of ureteric obstruction was judged suboptimal.

The case was settled for a moderate sum.

Learning points

  • Consent - Ureteric damage following hysterectomy is a known complication of this procedure. Patients should be made aware of it before undergoing surgery.
  • Supervision – The GMC’s Good Medical Practice advises that you should make sure that students and junior colleagues are properly supervised.
  • Delayed diagnosis of the complication - There should always be a high index of suspicion of visceral damage, particularly if sutures are placed in the corners of the vaginal cuff without direct visualisation of the ureter. It is essential to identify the problem and manage it effectively.

The particulars of claim included:

  • Failure to obtain informed consent and advise the patient of possible complications or problems that may arise from the hysterectomy.
  • Failure to provide doctors who would use reasonable care and skill when treating the patient.
  • Failure to properly diagnose that the patient’s postoperative symptoms were due to a right ureteric injury until the fifth