Patient was 50 years old at the time of the robotic-assisted laparoscopic prostatectomy performed by Dr. M. His medical history included hypertension, elevated cholesterol, hypogonadism and panic attacks. His medications included Klonopin, lisinopril and Vytorin. His endocrinologist wanted to start testosterone replacement therapy but first wanted him to have a PSA test. The PSA was elevated and he was referred to a urologist for further workup.
On 11/16/07, Dr.M performed a prostate biopsy in his office . The results of the biopsy showed adenocarcinoma with a Gleason score of 6. He recommended surgical removal of the prostate for treatment of the cancer. A robotic assisted laparoscopic radical prostatectomy was recommended. When asked how many prior robotic surgeries he performed defendant indicated he would be his 12th patient.
Surgery was 12/13/07. Instead of taking a couple of hours as previously discussed prior to surgery, the procedure took over 8 ½ hours. Part of that time was due to failure of the robotic equipment, though the exact time was never documented. Throughout this procedure, he was in the lithotomy position with his head lower than his feet. Pt was 6’2″ and weight 265lbs at the time of the surgery. Dr. told the family that the procedure was technically very difficult. The prostate was removed in 7 pieces and the pathology report showed no evidence of cancer. When asked why no cancer, he told the pt / pts family that the focus of cancer could have been totally removed at the time of the biopsy or was removed by the inflammation that occurred after.
Immediately upon waking up from anesthesia in the PACU, he began complaining of numbness in his left arm and left leg pain. He was given increasing doses of morphine for the pain unrelated to his surgery. Throughout the remainder of that day and into the night, his left arm/leg pain continued and increased in intensity. By the morning of 12/14/07, he was exhibiting weakness of the left side of his body in addition to the pain. Dr. ordered tests but never considered compartment syndrome or rhabdomyolysis; neither did the neurologist who felt there had been some sort of stroke or neurological injury.
Dr ordered an orthopedic consult in the early morning hours of 12/15/07 who found that this was a case of “missed compartment syndrome of the left upper extremity and compression neuropraxia (nerve damage) of both upper extremities” that was resolving. He felt that the 36 hour delay in arriving at the diagnosis made treatment less definitive. Pt developed renal insufficiency due to the toxins released by the dying muscle tissue but responded positively to increased hydration with IV fluids. After several days of treatment, he was able to begin Physical Therapy in order to begin to walk. He was transferred on 12/21/07 to a skilled nursing facility/rehab center for further treatment.
After months of continued pain, foot drop, development of tremors in both arms, in addition to continued urologic problems, including continued hematuria and incontinence, it had been discovered through testing that there was a retained foreign object that had been placed during the surgery that had migrated from the surgery site into the urethra. It was felt to be a Weck clip which had been used to reconnect the bladder to the urethra. While not unusual to use these types of devices used for surgery, migration into the urethra is uncommon and cause for concern.
Pt continues to have problems with foot drop which makes walking very difficult, dizziness, vision problems, nerve damage in his foot and hand, rosacea (felt to be due to nerve damage), diminished reflexes as well as worsening of his panic attacks (fears falling) and depression.
I think there is potential breach on several counts. First, the surgery was very long and the doctor should have considered converting from robotic to open. Second, the long surgery and positioning likely resulted in compartment syndrome and rhabdomyolysis. Third, there was an unnecessary delay in diagnosing the compartment syndrome.
The Weck clips are another matter. They are commonly used to minimize blood loss when separating the bladder from the prostate and are not used to connect the bladder to the urethra. Migration Weck clips are described and not uncommon with this surgery.
– Dr. SC