Chronic Renal Stones in a Pediatric Patient Results in an Eventual Nephrectomy

Allegation

Failure to recognize underlying problem caused by a ureteropelvic junction (UPJ) obstruction and diagnose a UPJ obstruction. Improperly performed Extracorporeal Shock Wave Lithotripsy (ESWL) and placement of ureteral stent vs. reconstruction of incision, improperly performed a laser to dilate the UPJ, and failure to perform a proper reconstruction or incision of the UPJ obstruction.

Case Details

A 14-year-old male was referred by his PCP to the defendant urologist with complaints of right flank pain, renal stones, nausea, and vomiting. History includes asthma, sinusitis, allergies, depression, and no history of renal stones. Medications include cetirizine, sertraline HCL, trimethoprim/sulfamethoxazole, and hydrocodone acetaminophen prn. CT revealed a large stone in the lower part of the right kidney and two smaller calcifications in the region of the UPJ, hydronephrosis, and either an extra renal pelvis or a UPJ obstruction thick parenchyma. The patient passed three stones the day prior to being seen in the office. A CT/IVP was ordered to assess for stone fragments and obstruction and found marked obstruction of the right kidney at the level of the UPJ, stenosis of the ureter at the UPJ producing moderate to marked obstructive changes to the right kidney, and renal lithiasis.

Three weeks later, the defendant urologist performed a cystoscopy with urethral calibration and placement of a right ureteral stent, ESWL with fluoroscopy. The renal scan noted normal perfusion to both kidneys, marked prolongation of half-time renal activity clearance of the right kidney pre-Lasix, and mildly prolonged post-Lasix. Possible significant stasis with component of partial obstructive uropathy probably at the level of the UPJ.

Four days after the cystoscopy and stent placement, an urgent visit to the hospital found right kidney stones and hydronephrosis. At a subsequent visit to the defendant urologist a review of the CT noted residual fragments consistent with ESWL and a stent in good condition. The patient was much improved and voiding well, and a KUB showed no residual stones. A UPJ repair was unwarranted as the draining time was only slightly delayed and the parenchyma was not thinning. The defendant urologist instructed the patient to increase fluids and return in two to three weeks for a recheck.

A week later, and based on patient complaint of back pain, an A/P CT revealed right renal calculi, right stent in place, and moderate right hydronephrosis. Overall, the exam was improved from the prior CT and KUB was normal.

A week following, upon the mother’s request, a refill of hydrocodone acetaminophen was prescribed.

Five weeks after stent placement, the patient complained of increased discomfort and requested removal of the stent. Based on a normal KUB and physical exam, the patient underwent a cystoscopy with urethral calibration and right stent removal.

Three weeks later the patient went to the ED after experiencing 10/10 right flank pain and vomiting. A CT revealed a 5mm ureteral stone and a nuclear renal scan showed normal kidney function. Four days later the defendant urologist performed a cystoscopy with urethral calibration, right retrograde pyelogram, ureteroscopy/nephroscopy, laser ablation, extraction of the stone fragments, and placement of a new stent. The UPJ was slightly narrowed, and the laser fiber was used to open it slightly. Several hours post-procedure the patient presented to the ED with severe pain. The KUB showed the stent in good position; however, the patient was admitted for pain control. Stent removal was scheduled for five days after discharge and one week after stent placement.

Two days following the stent removal the patient experienced severe pain at track practice. Rest and fluids were advised and a refill of phenazopyridine was ordered. Over the next two and a half weeks the patient presented to the ED twice for pain, was diagnosed with renal colic, and was started on antibiotic and pain medication. The urine culture was negative. The patient never returned to the defendant urologist.

Three months after the initial visit to the defendant urologist, the patient’s mother sought a second opinion and then a third opinion a few months later. Over the next several years the patient remained under the care of a urologist with bouts of kidney stones, and procedures including cystoscopies, stent placements and removals, and various other procedures and testing. Eventually after continuing to experience pain, the patient sought care from another urologist seeking a right nephrectomy, despite normal kidney function. The patient wanted definitive treatment and a right nephrectomy was performed. The patient subsequently experienced almost complete resolution of his chronic pain.

Expert Testimony

Plaintiff experts allege that the failure by the defendant urologist to diagnose and appropriately treat the UPJ caused edema, scarring, and worsening of the obstruction and led to difficult subsequent care by other providers. Based in part on the defendant’s documentation, defense experts were able to support the care provided.

Resolution

Defensible medicine and defense expert support resulted in a defense verdict in favor of the insured urologist.

Risk Reduction Strategies

Advise the patient and parent/legal guardian of the risks, benefits, and alternatives of available treatment. Document this discussion and the patient’s decision.

Document rationale for the treatment plan.

Communicate clearly the plan of care to patient and collaborating physicians.

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