One That Got Away: A Case of The Forgotten Ureteral Stent


  • Claire Otasowie University of Oxford
  • Kenrick Kai Chi Chan



Appropriate concordance between surgeon, patient and allied healthcare professionals is essential in preventing errors such as ureteric stents being left in situ. This case highlights the classic “Swiss cheese” model of errors leading to the described consequences. The case discusses pertinent points regarding appropriate pre-stent counselling of patients (although this may not always be feasible in the emergency setting), the emphasis on the surgeon who places a stent being responsible for arrange an appropriate management plan for the stent, the notification from the administrative team if a patient fails to attend follow up, as well as the joint responsibility between patient and surgeon to ensure the management plan is followed. Unfortunately, there is no widely used nationalised system in place for the recording and subsequent follow up of stent insertions. This usually either relies on the surgeon themselves to book / arrange follow up for the stent (sometimes with the help of the administrative team), and/or a stent registry such as the one described on the British Association of Urological Surgeons (BAUS) website. However, these locally arranged systems again may be prone to errors such as forgetting or incorrectly recording the stent insertion, emails to administrative teams being lost or not interpreted correctly, database corruption/errors/unavailability, or patients moving out of area.

Special care should be taken with patients who may be at a higher risk of having a forgotten stent. Specifically, those who may have no sensation of a stent, and those who may not fully understand the potential complications of not being followed up appropriately such as in this case. This report presents the case of Mr X, a 70-year-old man who presented with acute-on-chronic renal failure due to an extensively encrusted ureteral stent that had been placed to alleviate obstructive uropathy, and subsequently forgotten for almost two years.