The female urology case takes place in Iowa and involves a female patient with a past medical history of recurrent renal calculi. The patient had undergone multiple interventions for stones in the past and developed a stricture of the left ureter. This was treated with an indwelling stent. The stent was not successful and the patient continued to experience pain. The patient underwent a cystoscopy with extraction of ureteral stricture and left ureteroneocystostomy with psoas hitch. Following the surgery, the patient’s lower left extremity was completely paralyzed. It was determined that the cause was a stitch that was placed through the left femoral nerve inadvertently tethering the nerve during the procedure. A subsequent procedure was performed one week later to remove the stitch. The patient has since experienced extreme pain and weakness in her leg continuously since the initial procedure, and has had to pay numerous medical bills for neuromuscular and functional electrical stimulation to gain control of her leg.
Question(s) For Expert Witness
- 1. Do you perform ureteroneocystostomy with psoas hitch procedures? If so, how often?
- 2. What precautions should be taken to prevent injury to the genitofemoral nerves?
Expert Witness Response E-007170
I perform these cases several times per year, usually because someone was referred to me with a ureteral injury. The following are precautions to prevent nerve injury: careful control of blood loss, careful identification of psoas tendon, careful placement of stitches into tendon and not the nearby nerve, carefully written and explained informed consent form.
Expert Witness Response E-005320
I perform ureteroneocystostomy on average one to a few times per year. Although not a high volume procedure, it is one of the most common reconstructive procedures for distal to mid ureteral strictures. The Psoas hitch is performed suturing the bladder to the psoas muscle +/- psoas minor tendon. Surgical atlases often stress the importance of not including the genitofemoral nerve trunk which runs across the anterior surface of the psoas muscle. The femoral nerve is usually not seen. In the pelvic area, it runs in a groove between psoas major and iliacus giving off branches to both muscles. I assume this nerve was injured with deep suture placement. The surgical precaution is to be sure bladder held against psoas +/- psoas minor tendon above the common iliac vessels and to be sure that the sutures aren’t placed deep into the psoas or lateral to the lateral edge of the psoas muscle.