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Case Study: Orchidectomy Negligence
Jack, 43 years old, Salford
Jack has Congenital Adrenal Hyperplasia (CAH) diagnosed early in his life, for which he was treated with oral steroid medication.
When he was 43 years old, Jack presented at clinic with swelling of his left testicle. It was suspected that the swelling was cystic. An MRI scan of both testicles was performed and showed masses in both testes, not typical of testicular tumours, raising the diagnostic possibility of hyperplasic adrenal rests.
Jack was seen again and his Prednisolone dose was altered with a view to reducing the size of the masses in both testicles. However after a month his testicular masses had not regressed and were aching. He was referred to a Consultant Urologist and Jack was advised that he would probably need to have his left testicle removed.
Failures in medical treatment
Following a clinic appointment, the consultant was suspicious that Jack may have a seminoma in his left testicle and arranged for Jack to return the following week for a left radical orchidectomy (removal of testicle) and to biopsy the right testicle.
Following the operation, the Histopathologist was not informed that Jack had CAH, nor that Jack had bilateral testicular masses. He concluded that the left testicle contained was a leydig cell tumour and noted that the right testicular sample showed normal sperm and no evidence of neoplasia.
The consultant urologist observed that the malignant potential was difficult to ascertain but that in a small percentage of cases, the tumour may have a tendency to metastasise. Jack was subsequently advised that he should have his right testicle removed as well, due to suspicion that this also contained a leydig cell tumour.
The following day, Jack advised the consultant that he was keen to save some sperm to store, to enable him to have the chance of fathering children in the future. Jack provided his sample of semen, which he understood was for freezing / storage purposes.
Unfortunately, the sample was for analysis only and that a further sample would have to be provided for freezing / storage purposes.
Jack underwent a right radical orchidectomy. At no time prior to this surgery was Jack asked to provide a further specimen of semen for freezing / storage. He was asked whether he had provided semen for storage and Jack confirmed that he had done so, honestly believing that the sample provided had been for this purpose.
Having notified the hospital of the proposed claim, there then followed a rather unusual sequence of events in that Jack was asked to attend an appointment where he was advised that a mistake had been made and in fact, the correct diagnosis was not leydig cell tumour but rather, testicular tumour of the adreno genital syndrome (TTAGS).
The claim for negligence
JMW alleged that it was negligent to fail to ensure that the Histopathologist knew that Jack had CAH, and that MRI scanning had detected bilateral testicular masses. Had this been known to the Histopathologist, he would or should have suspected a diagnosis of TTAGS, which could then have been confirmed if necessary by referral to an expert.
The Histopathologist or Consultant should have performed a literature search in relation to CAH and, had they done so, they would have noted that bilateral testicular tumours are more likely to be TTAGS rather than leydig cell tumours. These are the only two differential diagnoses with testicular tumours. Only 3% of leydig cell tumours develop bilaterally, in contrast to 83% of bilateral tumours associated with TAGS.
JMW Solicitors claimed that if the TAGS tumour had been identified Jack would have avoided a right orchidectomy and that he would have been treated medically with sustained high dose medication. Jack now requires life-long hormone replacement therapy and testicular implants.
There was also a failure to arrange for the preservation of a semen sample, for the purposes of preserving the possibility of Jack fathering children in the future, which added to his suffering and long-term implications of this ordeal.