Round Table: Minimizing Litigation in Non-Mesh Pelvic Floor Surgery

Round Table: Minimising Litigation in Non-Mesh Pelvic Floor Surgery  

Deepa Gopinath, FRANZCOG, FRCOG, CU, MPhil, MD
Nepean Hospital, Sydney, Australia

Moderators: Dr Albert Decker (New Zealand)

Speaker: Dr Phillip Toozs-Hobson (United Kingdom), Dr Dudley Robinson (United Kingdom), Dr Jenny King (Australia)

Round Table: Minimising Litigation in Non-Mesh Pelvic Floor Surgery

This round table, moderated by Dr Albert Decker, explored how medico-legal risk can be reduced in non-mesh pelvic floor surgery through better prediction, prevention, documentation and postoperative care. The discussion focused on common but high-impact areas of risk, including postoperative voiding dysfunction, the role of preoperative urodynamics and intraoperative cystoscopy, and expectations around posterior repair for bowel dysfunction and recurrence. Across the session, the emphasis was on recognising foreseeable complications, counselling patients clearly, documenting decision-making and ensuring timely access to treatment when problems arise.

Dr Phillip Toozs-Hobson framed postoperative voiding dysfunction as an expected and foreseeable risk after pelvic floor surgery, rather than an unexpected complication. His central message was that medico-legal risk is reduced when clinicians actively predict risk, prepare patients preoperatively, and use prevention strategies such as catheter planning, postoperative residual checks and timely bladder drainage to avoid overdistension injury. He emphasised that failure to recognise retention early can lead to detrusor damage, recurrent infection, persistent voiding dysfunction and longer-term sequelae, particularly in older or frail patients with reduced physiological reserve. The key takeaway was to be proactive: look for voiding dysfunction, document risk and counselling, arrange early follow-up, and ensure timely access to treatment such as intermittent self-catheterisation or catheter support before temporary dysfunction becomes lasting harm.

Dr Dudley Robinson addressed the medico-legal value of preoperative urodynamics and intraoperative cystoscopy as tools for planning, counselling and early detection of complications. He emphasised that urodynamics remains controversial in uncomplicated primary stress urinary incontinence, where evidence and guidelines support selective rather than routine use, but becomes more valuable in mixed symptoms, voiding dysfunction, redo surgery, significant anterior or apical prolapse and assessment of occult stress incontinence. In prolapse surgery, he highlighted that testing with prolapse reduction can help counsel patients about postoperative stress incontinence, although the method used should be consistent and understood within each clinician’s own practice. His key takeaway was that investigations should be used when they change counselling or management, while intraoperative cystoscopy should be strongly considered in continence and prolapse surgery to identify bladder or ureteric injury early, allow immediate correction and reduce downstream harm and litigation risk.

Dr Jenny King (Australia) challenged the tendency to underestimate posterior compartment surgery as a simple “tighten, trim and flatten” operation. She emphasised that medico-legal risk often arises from oversimplifying anatomy, failing to distinguish rectocele from enterocele or apical descent, and giving patients unrealistic expectations about bowel symptom improvement. Key technical points included careful assessment of the upper, middle and lower posterior compartments, per rectal examination to exclude enterocele or small bowel descent, avoiding excessive vaginal skin excision or over-tightening, and reconstructing the perineal body using the appropriate perineal muscles rather than levatorplasty. Her key takeaway was that persistent or de novo bowel dysfunction may reflect intussusception, anismus, dyssynergia, neuropathy or constipation rather than rectocele alone, so conservative therapy, multidisciplinary assessment and careful counselling are essential before offering posterior repair.

The common thread across the discussion was that litigation risk is often reduced before the complication occurs: by anticipating foreseeable problems, explaining them honestly, documenting decision-making and having clear pathways for early recognition and treatment. Rather than practising defensively, the session encouraged clinicians to practise deliberately, with anatomy, patient expectations and postoperative follow-up given the same importance as the operation itself.