Improper performance of TURP
A 68-year-old man came to the ED with urge incontinence, low urine output, and severe pain.
by Wayne Wenske, Senior Marketing Strategist
and Stacey Agnew, Risk Management Representative
Patient presentation
A 68-year-old man came to a hospital emergency department (ED) with urge incontinence, low urine output, and severe pain. He had a history of diabetes, hypertension, obesity, and dyslipidemia. The Emergency Medicine (EM) physician examined him and diagnosed urinary tract infection (UTI). The patient was discharged with indwelling urinary catheter and a prescription for cefalexin to treat the UTI.
Four days later, the patient returned to the ED with hematuria, low urine output, and severe pain. He was scheduled for an appointment at the hospital with Urologist A for later that afternoon. However, the patient returned to the ED before his appointment because of worsening hematuria and pain.
Physician action
The patient was admitted to the hospital. Urologist A obtained consent from the patient to perform a cystoscopy to examine the patient’s urethra and bladder. During the exam, Urologist A encountered significant bleeding from the prostate. He evacuated large and extensive blood clots from the bladder. He then performed a partial transurethral resection of the prostate (TURP) and fulgurated the remaining bleeders. Urologist A did not obtain consent for the TURP.
That night, the patient reported a hard, uncomfortable abdomen. Urologist A returned the patient to surgery where he drained the distended bladder and extraluminal air and fluid in the peritoneal cavity by probing with a straight catheter. The patient was discharged three days after being admitted.
Approximately six days later, the patient returned to the ED because he had developed fecaluria through his indwelling urinary catheter. A CT scan of the abdomen revealed that the catheter was perforating through the posterior aspect of the prostate into the distal rectum.
The patient was admitted under the care of Urologist B. Urologist B took the patient to surgery the next day and performed a suprapubic subtotal prostatectomy and ileostomy to repair the rectovesical fistula.
Following the prostatectomy, the patient became bed-ridden due to his dependency on an ileostomy bag. He was also diagnosed with severe depression.
Allegations
A lawsuit was filed against Urologist A for improperly performing a TURP procedure without consent, which led to the injury between the prostate, bladder, and rectum.
Legal implications
Expert consultants for the defense expressed mixed opinions. One of the experts believed the defendant fell below the standard of care for injuring the patient during the TURP. The injury led to the formation of a recto-urethral fistula which complicated the reconstruction of the patient’s urethra and rectum. However, another defense expert argued that formation of a recto-urethral fistula is a known complication of TURP.
Both consultants noted that Urologist A did not order imaging during the procedure or after the drains were inserted. He also did not order a repeat CT scan before the patient was discharged. Had imaging been conducted, the patient’s injuries may have been identified and treated earlier.
Plaintiff’s consultants described Urologist A’s treatment as “too aggressive” and stated that he could have opted for more conservative treatment. Each of the plaintiff’s consultants felt Urologist A’s performance of the TURP caused the patient’s injury, infections, and complications.
The plaintiff’s consultants also stated that placing drains in the retro/peritoneal spaces was an outdated technique. It was also noted that Urologist A mispositioned the indwelling catheter on two occasions and failed to identify the misplacement.
Documentation was a weakness in this case. Urologist A did not describe what he observed and encountered intraoperatively. He also did not document the patient’s progress post-surgery. Urologist A’s failure to obtain consent for the TURP was considered one of the biggest challenges to the defense.
Disposition
The case was settled on behalf of Urologist A.
More on improper performance.
Disclaimer
This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.
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