This case involves an adult woman who underwent laser lithotripsy surgery for an impacted ureteral stone. During the surgery, a perforation of the ureter complicated the procedure, and the surgeon placed an intraoperative stent to correct the injury.
Despite suffering from unresolved excruciating postoperative pain and surgical complications, the patient was discharged a few days later.
The patient continued to complain of pain for two weeks following discharge. However, the physician's office advised the patient “not to worry about it.” Three weeks after the lithotripsy procedure, the patient went to the Emergency Room and was diagnosed with hydronephrosis, kidney abscess, and septicemia. Following this diagnosis, the patient was transferred to another center for treatment. Unfortunately, the patient ultimately required a nephrectomy.
Most ureteral stones are currently managed using holmium laser lithotripsy. While it is considered a minimally invasive procedure, the surgery has known, troublesome complications, including ureteral damage and stricture. Thermal injury to the ureter is most often caused by holmium laser firing as in this case.
Hydronephrosis occurs when a blockage or obstruction of urine outflow, or reflux of urine from the bladder builds and collects in the kidneys. Hydronephrosis can result from surgical trauma, which causes the renal pelvis to enlarge.
Hydronephrosis may or may not be symptomatic. The main symptom is generally pain, either on the side and back, abdomen or groin. In this case, the risk factors for hydronephrosis were greatly increased due to scarring of tissue and ureter injury requiring a stent.
As one of the late complications of URL, ureteral stricture can lead to ureteral obstruction and progressive renal function decline. Irreversible renal failure may occur if routine postoperative follow-ups are not conducted.
Ureteral stricture complications are also influenced by comprehensive postoperative imaging follow-up care. In this case, the ureteral stenosis remained undetected due to insufficient imaging, and below standard care that led to kidney failure resulting in kidney loss.
Question(s) For Expert Witness
- Do you perform laser lithotripsy frequently on stones in the ureter?
- How can one prevent damage to the ureter when performing laser lithotripsy? What steps are necessary when an intraoperative ureteral perforation is found?
- Are you available to review 700-1000 pages and provide an opinion and sign an affidavit of merit if prudent?
Expert Witness Response
I am an academic urologist who has been in independent practice for over 10 years. I have a faculty appointment at a top 10 university, and I am a specialist in kidney stone surgery at one of the largest kidney stone centers in the Midwest. To prevent damage to the ureter when performing laser lithotripsy, you must carefully place a wire, usually hydrophilic, past an impacted stone. Sometimes perforation cannot be avoided, especially if a stone is impacted in the ureter. The level of follow-up required may depend on how severe the perforation is. Minor perforations can be managed with a stent for 4-6 weeks, with follow-up in the clinic to remove them. More significant perforations might require antibiotics, a prolonged stent (longer than 4-6 weeks), with return to the operating room to ensure the perforation has healed with radiographic guidance.