‘Forgotten’ ureteral stents: Whose responsibility?

A nightmare session is based around disastrous cases. It particularly highlights the ethical and legal implications for the treating urologist, beyond the immediate medical effects of the treatment. It should be noted that the case presenters were not the urologists involved in the case in question, but they were tasked with defending the procedure against Mr. Leigh’s intense questioning.

Experts from the EAU’s urolithiasis section (EULIS) gave additional information about ongoing research and current practice for each case.  Mr. Leigh joined the Annual EAU Congress for the third time, having previously grilled kidney and bladder cancer specialists at EAU17 and EAU18 respectively.

The forgotten stent

As the nightmare session got underway, co-chairman Mr. Tim O’Brien (GB) polled the audience to see how many of those present had ever accidentally left a stent in a patient. Between five and ten percent of the audience raised their hands.

Assistant Prof. Kaloyan Davidoff (BG) presented a case from a German-speaking country, in which a 32 year-old Albanian woman had an emergency caesarian section and sustained ureteric injury. The urologist placed a JJ stent. The patient returned at four, six and eight months with a urinary tract infection, visible haematuria and pain.

It was only 14 months after the childbirth that she was referred back to the urologist who found the severely encrusted stent. In the end, a combination of punch lithotripsy, URS and laser lithotripsy were used to dismantle the stent. Three SWL sessions were then required to completely remove the remains of the stent. The patient had endured constant bladder pain and recurrent urinary infections, and complained that she had not bonded properly with her child. The case was further complicated by the fact that the patient did not speak German.

Former EULIS Chairman Prof. Palle Osther (DK) added some background information to the complications and procedures in this illustrative case: “13 out of 100 ureteral stents will be forgotten, ten of which will become encrusted, with increased risk of infection and obstruction.”

“As a urologist, you might think ‘it’s not my job’, but it most definitely IS your job to monitor your patients’ stents,” Osther emphasised. He offered a variety of possible approaches beyond a card register: an electronic registry that warns the urologist when placed stents are set to expire, and closer involvement of the patient, equipping him or her with wristbands or smartphone apps. (As with all good shows, Prof. Osther finished on a song: an ode to the gentle urologist with a self-penned Ureter Song.)

Cross-examination

Mr. Leigh’s subsequent cross-examination of Prof. Davidoff and his case yielded many interesting questions that the urologist must consider around stent use. Further discussion with the panel members and the audience offered insights in current practice around the world.

“Did you make a serious effort to contact the patient?” Mr. Leigh asked. “Did you explicitly and adequately inform the gynaecologist or GP? Is a language barrier, or a claim of patient ignorance, really sufficient to escape blame for this negligence?”

Further discussion led to Prof. Osther referencing the hospital’s responsibility, or even in some cases the existence of a national stent database that monitors placement and removal. Solutions offered by the panel and the audience included co-signed forms, the suggestion that every new stent also include a distinctive wristband for the patient, and the creation of stent guidelines, for instance from an international body such as the EAU.

The nightmare session continued with two further cases: severe sepsis following ureteroscopy and bowel injury as a result of percutaneous nephrolithotomy. Both cases were discussed and subjected to questions of legality asked by Mr. Leigh to each case presenter.

EAU TV spoke with Mr. Leigh and Prof. Osther in the EAU19 studio to discuss about the procedures and responsibilities. See the video interview here.