Delays in removing Ureteric Stents

Stephanie Prior

In February 2020, the Health Care Safety Investigation Branch (HSIB) published an interim bulletin in relation to the ‘Unplanned delayed removal of ureteric stents’.  I was interested in this as I have had quite a few medical negligence cases, whereby female patients have suffered an injury to the ureter during routine surgery and this has not been spotted until quite some time after the initial injury to the ureter. This in turn led to urine leaking into the internal cavity and all of the clients having to undergo complex urinary surgery to repair the damage.

This complex surgery in all cases required insertion of a ureteric stent.

The stent is a thin tube which is inserted into the ureter to keep it patent and prevent or treat obstruction of the urine flow from the kidney. In the cases I was involved in the ureter had been accidentally cut and the stent enabled the ureter to be repaired and allow it to heal once sutured back together.  In many cases stents are used when there is blockage of the ureter due to kidney stones; external compression, scarring etc.

In all cases the stent was temporary and had to be removed within a specific time frame. In all cases this did not happen and the stents were left in for too long. In one case the stent had been left in for nearly a year in error and this caused my client to suffer inflammation which led to urgency and frequency of urination.

The HSIB received a Safety Awareness Notification from a large teaching NHS Trust as there was an issue at that NHS Trust with the retention of ureteric stents not being removed in a timely fashion which led to the stent becoming ‘encrusted’ which caused the patient harm and leads to them possibly having to have the stent removed by a urologist under a general anaesthetic. That is exactly what happened in each of my cases.

The HSIB report quotes a paper by Bultitide et al (2003) which says:

‘If a ureteric stent is left in for a long time it can become more difficult to remove, leading to a longer hospital stay, extended recovery time and is associated with increased morbidity. It can affect a patient’s long –term kidney function and can lead to iatrogenic loss of a kidney (loss of an organ due to medical intervention). If bilateral, loss of both kidneys can occur necessitating dialysis of transplant.’

Safety risks of stents

The report referred to a case which involved a patient with a complex medical health history who had a ureteric stent in situ for over a year and the stent had become severely encrusted and had affected the patient’s kidney function.  This case highlighted potential national safety risks and included:

• The use of stent registries
• Patient communication
• Kidney/ureteric stone care in hospitals
• Waiting times and access to clinic appointments
• Provision of non-medical support staff to support the kidney/ureteric stone care pathway

Further the HSIB report highlighted the ‘Getting it Right First Time’ on urological services and this revealed that out of the 140 hospital trusts providing urology services there was ‘significant’ variation in clinical practice. This means that they are not all doing the same thing. Hence, this leads to human error and one of the issues identified related to a how the insertion of stents was being recorded.  Some hospitals using a stent register and some are not.

The other issue was that some patients did not understand the purpose of the stent or the consequences of the delay in removal. In one of my cases, my client’s first language was not English. She did not speak any English and therefore was unaware that the stent had been left in for too long. In fact, if had nearly been a year before it was removed.

GP’s should also know if their patient has a stent and for how long it is supposed to be in situ. The HSIB report highlighted the issue of tracking stents. It therefore makes sense if the patient and GP are informed and are aware of when the stent has to be removed, then the treating hospital doctor can be chased up if an appointment for removal is not fixed in a timely manner.

If a patient has other underlying health issues, such as cancer; cardiac problems etc this may distract from the urological pathway.  They may end up getting ‘lost in the system’ because their other medical health needs are being focussed on.

The HSIB is continuing to explore the identified safety issues and its investigation will focus on:

‘The pathways of care for patients:

• With acute presentations of kidney stones
• Undergoing planned surgery for kidney or ureteric stones, including how ureteric stents are used, registered, monitored and removed.

As well as the arrangements for patients being followed up as an outpatient. This will be limited to the factors relevant to stones and stents as HSIB are currently undertaking an investigation which will look in detail at outpatient booking arrangements and follow-up’.

We await the final report and hope that the report will create consistency for all 140 hospital trusts with urological services.

Blog post written by Stephanie Prior, head of Clinical Negligence department.