This case involves a patient who underwent an elective vasectomy. He started to experience pain for 3 days after his procedure and went to see the surgeon. The surgeon told him the pain should subside, and in the meantime instructed him to take pain medications. He had continuous pain for the next 2 months for which he repeatedly went to his doctor. He was later found to have developed chronic pain syndrome. The American Academy for Urology guideline states that prior to this procedure, the operating physician must formally communicate that chronic pain syndrome is a potential outcome of this procedure. In this instance, the patient was not informed, and suffers ongoing distress and severe discomfort.

I perform 250 vasectomies per year. As a reviewer of the AUA Guidelines on vasectomy, I am well aware of the warnings regarding chronic pain syndrome that should be given to patients prior to performing a vasectomy.

1. Do you perform vasectomies? 2. Are you familiar with the guidelines that require a physician to inform a patient that chronic pain syndrome is a potential outcome of this procedure?

Location, TN BS, Medicine, Northwestern University MD, Northwestern University Internship, General Surgery, Northwestern University Residency, General Surgery, Northwestern University Residency, Urology, Northwestern University Fellowship, Male Reproductive Medicine & Surgery, Baylor University Research Scholar, American Foundation for Urologic Disease, Baylor University Board Certification, American Board of Urology Member, American College of Surgeons Member, Sexual Medicine Society of North America Member, Society for the Study of Male Reproduction Reviewer, 5+ Medical Journals Published, 125+ Peer-Reviewed Journal Articles Presenter, Numerous National and International Lectures Honor, America's Top Doctors x7, Castle-Connolly Current P******** o* U********* S****** a M**** M****** S***** Current A***** S**** a M**** H*******

This highly qualified expert is board-certified in urology and has been practicing for over 17 years. He completed both his internship and residency training in urological surgery at Northwestern and then completed his fellowship training at Baylor. He was also a research scholar at the Male Reproductive Foundation for Urological Disease at Baylor. He is a fellow of the American College of Surgeons and a member of multiple other professional organizations, including the Sexual Medicine Society of North America and the Society for the Study of Male Reproduction. He is well-published and serves on the editorial board for several renowned medical journals. He lectures both nationally and internationally and was listed as one of "America's Top Doctors" for 7 consecutive years. Currently, he is a professor of urology at a major medical school.

Elective Vasectomy Leads to Chronic Pain Syndrome

This case involves a 37-year-old male who underwent a vasectomy. The surgeon noted there was a prominent blood vessel in close approximation to the vas deferens that took extra time to control. The day after the operation, the patient presented to emergency department of the hospital with significant swelling and severe pain radiating from his left groin. An ultrasound appeared to show compromised blood flow. The radiology impression determined his testicle was inflamed and he was discharged with antibiotics. The patient continued to feel excruciating pain and the next day, he was taken to emergency deparment of a local hospital where he underwent an exploratory surgery. The spermatic cord was found to have a significantly large hematoma. The surgeon attempted to treat the hematoma, but clotting was so severe that she had to perform a orchiectomy.

If a patient presents to the ER with compromised blood flow and vascular insufficiency, they should immediately be evaluated by urology services. If this is not possible, they should be transferred to a hospital where urology services are available immediately.

1. If a patient presents to the ER with compromised blood flow and vascular insufficiency, what steps should be taken? 2. Have you ever reviewed a similar case? If yes, please elaborate.

Location: PA BS, Pennsylvania State University MD, Jefferson Medical College Residency, Emergency Medicine, Thomas Jefferson University Hospital Board Certified: Emergency Medicine Member, Society of Academic Emergency Medicine Member, American College of Emergency Physicians Current A******** P******** E******** M******* a d************ u********* Current V******* A******** P******** E******** M******* a f****** u********* Current D******* a r******* v******** c***** Current D******* a u******************** f****** h******* Current C********** C******* T************ R******* D******* a P* m****** c******

This board-certified expert earned his combined BS/MD from Pennsylvania State University and Jefferson Medical College. He completed his residency training in emergency medicine at Thomas Jefferson University Hospital. He is a reviewer for several medical scientific journals and has authored over 110 peer-reviewed articles and abstracts. He is a member of several reputable societies including the Society of Academic Emergency Medicine and the American College of Emergency Physicians. In his current positions, he is actively involved in mentoring, supervising and lecturing medical students, residents, and fellows. He is an associate professor of emergency medicine at a tertiary care level 1 trauma center that receives a great deal of specialty patient transfers from hospitals in the region. He also serves as a faculty lecturer at a major university-affiliated medical center and as the director and co-director of two major foreign universities. Additionally, this expert is a FAAEM and FACEP physician and works many shifts with his academic center's affiliate branded urgent care centers.

Vasectomy Leads to Large Hematoma

This case involves a 52-year-old male patient who presented to his urologist’s office for a vasectomy. Before the operation, there was some discussion concerning a possible growth on one of his testicles. The patient indicated he never had pain in this area, and the urologist did not evaluate further. During the operation, the patient experienced right scrotal bleeding which prompted the urologist to transfer him to ER. At the ER, the urologist performed an exploration of left hemiscrotum, and performed a epididymectomy. The patient had to use a drain for 5 days and suffered intense pain for several weeks. As a result of the events – what was supposed to be a short procedure turned into a long ER visit and further complications.

I am a board certified Professor and Chief of Urology, as well as the Urology Residency Program Director for my hospital. I perform about 100 vasectomies per year. These are both done in the office and in the hospital setting. Routine vasectomies are rarely followed by ER visits unless a complication occurs such as bleeding or severe pain. Patients needs to be well appraised of complications of this procedure which are quite rare. The left scrotal bleeding in this case may be due to difficult anatomy or an underlying mass that was not detected. In this case, it also sounds like there was poor communication with the patient which certainly did not help the situation.

1. Do you have extensive experience performing vasectomies? 2. Is a routine vasectomy typically followed by an ER visit?- what complications can be avoided by following proper procedure? 3. Is left scrotal bleeding a common complication of vasectomies?

Botched Vasectomy Forces Patient to Undergo Epididymectomy

This case involves a 49-year-old male patient from Michigan who underwent a vasectomy. Within an hour of the procedure, the patient called about brisk bleeding, but the doctor did not seem concerned and told him to call if the problem persisted. The patient called the doctor multiple times about the significant amount of bleeding and no matter how much pressure was placed, the bleeding would persist. After only 3 hours of being discharged the patient returned to the doctor’s office with excessive bleeding. The surgeon put a stitch in a vessel and told the patient the bleeding would stop soon. However, the bleeding continued and follow up calls did not result in further care. Within 3 days after the stitch was placed, he was sent to the ER by his family physician with a significantly enlarged testicle and extreme pain. It was found that his scrotum was filled with blood, and he later developed an infection in the testicle.

If an initial stitch does not stop bleeding, you need to go to the operating room, extend the excision and definitively control the bleeding. I have reviewed similar cases two or three times. Invariably, the initial inadequate response by the operating physician leads to such a complication which is avoidable. Bleeding is a risk of any procedure but since the operation seems "minor" in the mind of the physician the response to the complication may be initially inadequate. As in many cases, the real problem is not the complication per se but failure to take remedial action promptly.

1. How often do you perform this procedure? 2. If a patient is bleeding briskly before the procedure ends, is it appropriate to address the bleeding prior to releasing the patient? 3. If a stitch in a vessel does not control bleeding, what steps need to be taken? 4. Have you ever reviewed a similar case? If so, please explain.

Location: CA B.A., Stanford University M.D., University of Utah College of Medicine Internship, Surgery, UCLA Hospitals and Clinics Residency, General Surgery, UCLA Hospitals and Clinics Board Certification: Urology Member, American Medical Association Member, American Urological Association Member, American College of Surgeons Published, 9 peer-reviewed medical publications Former A****** A******** P******** o* U****** U*** Former C******* A******** P******** o* U****** U*** Former C**** o* U****** V***** P*********** H******* Former C**** o* S****** S********* M******* H******* Former C********* O**** V*** M****** C***** Current F****** 4 m**** h******* a*********** Current R****** U********* S****** a m**** C* u****** g**** Current A******** M****** D******* f** U****** a* i********** m****** g****

This actively practicing, Da Vinci-trained urologist has remained in active practice for more than 30 years. He received his BA from Stanford University and his MD from the University of Utah College of Medicine. He completed an internship and a residency in General Surgery at UCLA Hospital and Clinics. He has acquired memberships in such prestigious organizations as the American Urological Association and the American College of Surgeons, where he is also a fellow. His impressive resume includes prior appointments as the Chief of Urology and Chief of Surgery at major California health care institutions. These strong qualifications make him extremely capable of reviewing this case.

Botched Vasectomy Leads to Significant Bleeding and Infection

This case involves a 43-year-old patient who had a reverse vasectomy after consulting his partner. However, soon after the procedure he started to experience severe testicular pain and swelling. It was found he had developed a hematoma in his scrotum and his urologist decided it would be best to drain it. However, during the procedure, the urologist’s incision was misplaced and instead hit a nerve in the area. The patient subsequently suffered permanent nerve damage and is no longer able to conduct daily activities without pain or discomfort.

I treat many patients who have nerve entrapment after pelvic surgeries. I feel comfortable determining if the nerve damage could have been caused by the surgery and the cost of future care.

1. Please explain why you are qualified to review this matter. 2. Have you ever reviewed a similar case? If yes, please elaborate.

Location: IL BA, Chemistry & Psychology, Cornell University MD, Cornell University Internship, Beth Israel Deaconess Hospital Residency, Anesthesiology, University of Pennsylvania Fellowship, Interventional Pain Medicine, Hospital of the University of Pennsylvania Board Certified: Anesthesiology, Pain Medicine Member, International Spine Intervention Society Member, American Society of Anesthesiology Former P******** a** O**** L** A****** P*** M********* P********* Former C**** M****** O****** M****** P*** a** S******* S********** Former P*** M********* P******** C********** C************ P*** Current A****** L******* a m****** s***** i* I******* Current S**** P******** P*** M********* s****** h******** i* I******* Current P*** M********* S********* a p****** p*** m********* c***** i* I*******

This expert is board certified in pain management and anesthesiology. He earned both his BA and MD from Cornell University. He completed his internship at Beth Israel Deaconess Hospital and his residency in anesthesiology as well as a fellowship in interventional pain management at the University of Pennsylvania. He is a member of the American Society of Anesthesiology and has published 9 peer-reviewed articles in addition to multiple abstracts, book chapters, and white papers on pain management. He formerly served as the president and owner of Los Angeles Pain Management Physicians, as chief medical officer of Medicos Pain and Surgical Specialists, and as a pain management specialist at Continental Comprehensive Pain. He currently serves as an adjunct lecturer at a major medical school in Chicago, as a staff physician at two Chicago hospitals, and as a pain management specialist at a private pain management center in Chicago.

Doctor Severs Nerve During Reverse Vasectomy

This case involves a male patient who underwent a reverse vasectomy. For 2 days after the procedure, the patient experienced continuous pain and incontinence. He called the hospital multiple times but was only told to take pain medication. On the second day after his operation, the patient could not withstand the pain and incontinence anymore and presented to the emergency department. Further workup identified a hematoma in the patient’s scrotum, which was blocking blood flow to the testicle. The patient’s urologist was contacted, who said he had some difficulties during the procedure because the prior vasectomy incision was unusually placed. He stated that there was some concern for the vascular inflow of the testicle, although at the end of the procedure, blood flow seemed normal. The patient was not informed of the complication at any point after the surgery. The patient has since undergone multiple surgeries, but has since lost fertility.

I am a specialist in vasectomies, vasectomy reversals, genital reconstruction, male fertility and microsurgery, and sexual health. I perform 2-3 vasectomy reversals per week and 5 vasectomies. Loss of a testicle following vasectomy reversal is not a common complication. I am not sure if the reversal was performed microsurgically or not, which is the standard of care. Certainly a hematoma can occur postoperatively following scrotal surgery, but a hematoma itself should not occlude blood flow to the testicle. It sounds concerning that an arterial injury occurred at the time of reconstruction. If the surgeon had thought that an artery was damaged at the time of surgery, but upon further inspection it appeared fine, then that is not necessarily something that needs to be discussed with the patient. However, if an arterial injury did occur, and it was repaired or intervention taken to address this possible injury, then yes this should have been discussed with the patient. Full disclosure is generally the best practice.

1. Do you have experience performing vasectomies? 2. Are you familiar with the complication that occurred in this case? 3. Should the patient have been informed of the difficulties/complications encountered during the surgery?

Location: MD BA, Harvard University MD, Albany Medical College Internship, General Surgery, Johns Hopkins Hospital Residency, Urologic Surgery, Johns Hopkins Hospital Fellowship, Reproductive Medicine & Surgery, Baylor College of Medicine Board Certified: Urology Member, American Society for Reproductive Medicine Member, International Society of Cosmetogynecology Member, American Academy of Cosmetic Surgery Member, International Society for the Study of Women's Sexual Health Member, Sexual Medicine Society of North America Member, American Urological Association Former A******** P******** U****** O********* a** G********* T** J**** H****** H******* Current D******* F******** M*********** a** S***** H***** a M* p****** g**** p******* Current C******* I********* U****** a m**** D* m****** c***** Current F****** a** D******* a M* a******** s****** c***** Current R******* D******* a M* f******** c*****

This highly qualified, board-certified expert earned her bachelor's degree from Harvard University and her medical degree from Albany Medical College. This was followed by an internship in general surgery at the Johns Hopkins Hospital and a residency in urology at the Johns Hopkins Hospital. She then pursued her fellowship training in reproductive medicine and surgery at Baylor College of Medicine. This expert is a member of numerous prestigious medical societies including the International Society of Cosmetogynecology and the International Society for the Study of Women's Sexual Health. She is also a reviewer of 2 prestigious medical journals and has authored 17 peer-reviewed journal articles, 3 book chapters and 10 abstracts in her field. She has previously served as an assistant professor of urology, obstetrics and gynecology at The Johns Hopkins Hospital. She currently serves as the director of fertility, microsurgery and sexual health at a private group practice, as a clinical Instructor of urology at a major university hospital center, as the founder and director of an aesthetic surgery center, and as regional director of fertility at a reproductive science center.

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Vasectomy Expert Witness Case Studies

Elective Vasectomy Leads to Chronic Pain Syndrome

Vasectomy Leads to Large Hematoma

Botched Vasectomy Forces Patient to Undergo Epididymectomy

Botched Vasectomy Leads to Significant Bleeding and Infection

Doctor Severs Nerve During Reverse Vasectomy

Vasectomy Reversal Impedes Blood Flow to Patient’s Testicle

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