Allegation
Patient brought suit against the defendant urologist alleging improper follow-up led to loss of function in his right kidney.
The Case
The patient, a 53 YOM (5’9”, 140 lbs.), presented to the defendant urologist with complaints of gross painless hematuria. The patient’s history was significant for HTN, severe anxiety, alcoholism, elevated cholesterol, and chronic fatigue. He was a 1.5 PPD smoker, and had a history of urolithiasis and treatment for a left-sided stone 20 years earlier. A urinalysis demonstrated TNTC RBCs and a count of 0-1 WBCs (0-5 per hpf). The defendant urologist scheduled a CT urogram and an anesthetic cystoscopy for the following week to rule out a bladder tumor, renal cancer, and renal calculi.
The CT urogram showed the left kidney was unremarkable with no evidence of stone or hydronephrosis. The right kidney demonstrated some tiny 1-2 mm calcifications in the lower pole, and a 1.2 cm stone in the right renal pelvis. The stone did not appear to cause any hydronephrosis. An abdominal KUB x-ray was consistent with the CT showing the renal size, position, and shapes as normal. The ureters were symmetric.
The patient called the office requesting test results five days later. The results were fastened to the patient’s chart and given to the defendant urologist for follow-up. Two days later, the defendant urologist documented that he informed the patient and reviewed the test results.
Two months later, the patient underwent cystoscopy, left ureteroscopy, and left retrograde pyelogram. The procedures revealed no tumors, foreign bodies, or stones, and failed to indicate the source of the bleeding. The urine cytology was negative. The patient was given a prescription for Keflex® and Vicodin®, and instructed to follow-up with the defendant urologist.
The patient returned to the urology practice two days after the procedure with complaints of dysuria, hematuria, suprapubic discomfort, left flank pain, and left lower quadrant tenderness. He also described having cold sweats, nausea, and vomiting. He was evaluated by a PA at the practice, and told he was experiencing normal postoperative symptoms. His urinalysis continued to show TNTC RBCs, and a urine culture was negative. The patient was prescribed additional Vicodin and his Keflex was extended.
Two weeks after the procedure, the patient returned for a follow-up appointment. The defendant urologist noted that the urine cytology was negative. Urinalysis showed 20-30 RBCs and protein greater than 300 (0-14 mg/dL). The patient’s BUN and creatinine were normal at 11 (7-20) and .9 (0.3-1.3), respectively. The patient’s test results were forwarded to his PCP, and he was instructed to follow-up with the defendant urologist in one month.
The patient missed his follow-up appointment with the defendant urologist. He did not return to the practice, even after multiple attempts to reschedule. The defendant urologist had no further contact with the patient.
Two years later, the patient was referred to a different physician in the urology practice for gross hematuria. He underwent a CT urogram which showed right-sided hydronephrosis, and what appeared to be a 1.5 cm stone located in the proximal right ureter. The right kidney was atrophic and there was also a slight delay in renal function. The left kidney contained a partial staghorn calculus in the upper pole, as well as a normal appearing cortical thickness and possible mild scarring involving the upper pole laterally.
A cystoscopy was performed and showed no function of the right kidney and normal function of the left kidney. The staghorn stone was treated using a combination of percutaneous nephrostolithotomy and extra corporeal shockwave lithotripsy. A post-procedure KUB x-ray showed no obvious stones. The patient was free of pain and reported no hematuria. The patient subsequently filed suit alleging failure to properly manage and follow-up on right-sided kidney stone resulted in a complete loss of function in that kidney.
The patient’s expert witness stated that any renal calculus 6 mm or larger must be treated with lithotripsy. He conceded he could not rule out the possibility that the plaintiff formed a second renal calculus that ultimately blocked the ureter after passing the 1.2 cm calculus in question. The expert witness also acknowledged that the defendant urologist’s plan for the patient to come back for further evaluation in one month was appropriate and within the standard of care.
Defense experts were supportive of the treatment provided by the defendant urologist. They stated it was appropriate for the urologist to first investigate the potential for urothelial carcinoma in light of the patient’s painless hematuria and history of smoking. An additional expert testified that because the stone was not in the ureter, it was appropriate to complete the cancer work-up before addressing the stone.
Verdict
Due in part to expert witness support and the defendant urologist’s credibility on the witness stand, the jury found in favor of the defense.
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