Negligent Stone Removal Causes Mucosal Avulsion Injury

Konstandinidis v. Montgomery General Hospital, Inc. & Chesapeake Urology Associates

Stone BasketThis is an invasive procedure medical malpractice lawsuit filed against Montgomery General Hospital, Chesapeake Urology Associates, and two urologists. This case alleges that one of the defendant doctors caused a mucosal avulsion injury to the patient's ureter during the surgical removal of a ureteral stone. It was filed in Health Claims Arbitration on May 5, 2017 and it is the 212th medical malpractice case filed in Maryland this year.

Summary of Plaintiff's Allegations

A man came in to the Emergency Department at Montgomery Medical Center with a complaint of severe left flank pain. A CT scan showed a ureteral stone (proximal left ureteral calculus) and associated left hydronephorosis and proximal hydroureter. After an evaluation, the defendant doctor recommended cystoscopy with stent insertion, in preparation for extracorporeal shock wave lithotripsy, even though the Montgomery Medical Center did not have the means to perform the procedure. The defendant, instead, planned to attempt stone removal by other means, and if he was not successful, he would stent the left ureter and schedule a lithotripsy for a later date.

The defendant, after the planned cystoscopy with left retrograde balloon dilation of the left ureter, performed an ureterostomy and used a filiform-tip stone basket to extract the stone from the man's ureter. During the extraction process, the stone came out of the basket several times. When trying to re-grasp the stone, the defendant caused a mucosal avulsion injury to the ureter - there was a visible segment of ureteral mucosa in the stone basket. The procedure was then terminated without stent placement. For the purposes of urine drainage, a percutaneous nephrostomy tube was placed in the man's left kidney the next day, and a three-way catheter was placed for bladder irrigation. Ultimately, at a later date the man would have to undergo surgical repair of the ureteral mucosal avulsion injury caused by the defendant doctor.

During a second cystoscopy, the second defendant doctor noticed that the left ureter was inflamed, and despite multiple attempts, it was not possible to pass a catheter and guidewire. The second defendant doctor also attempted to repair the man's ureteral mucosal avulsion injury with a ureteral implant, but he encountered a great amount of edema, a necrotic left ureter, and an edematous gonadal vessel. A general surgeon was called, who litigated the vessel, examined the bladder, and determined that they were not in good condition to continue the repair. Once again, the procedure was terminated.

The man remained at Montgomery Medical Center until he could recover from the multiple failed procedures well enough to seek treatment at another facility. Once stable enough for discharge, the man went home where he received continuing nursing care and physical therapy. A urologic surgeon at Johns Hopkins Hospital recommended reconstructive surgery, among other things.

While the man was recovering at home, he began developing left flank pain and a fever, and two days later he went to the Emergency Department at Hopkins. He underwent tube nephrostogram and nephrostomy tube replacement to treat his sepsis and pyelonephritis (kidney infection). He was discharged home the next day. One month later, the man was admitted to Hopkins for his ileal ureter construction. He later returned for post-operative outpatient care, including stent removal and nephrostomy tube removal. Although the reconstruction was a success, the man continued to suffer persistent left flank pain, hydronephrosis, and urinary incontinence as a consequences of his ureteral mucosal avulsion injury.

Additional Comments
  • What should've been a simple outpatient procedure became a six-surgery ordeal over three months.
  • The standard of care requires the urologist to maintain adequate visualization of the stone, ureteral wall, and the basket throughout the entire stone retrieval process. This allows you to see where and what you are cutting. The standard of care requires that forceful manipulations should be avoided while performing stone retrieval. The surgeon should never attempt to retrieve a ureteropelvic stone intact, unless it is exceptionally small. The stone is broken up using intracorporeal lithotripsy. Then the urologist lets the smaller fragments to pass spontaneously.
  • An avulsion injury to the ureter is possibly the most devastating complication of ureteroscopy, occurring less than 1% of the time. Other unlikely risks include infection or bleeding.
  • While shock wave lithotripsy is the most common treatment for stones located in the kidney, ureteroscopy is more commonly used for stones in the ureter closest to the bladder. If the stone is too large or stuck too tightly, using a basket for removal can cause damage. In which case, the surgeon may opt for another ureteroscopy method, like using a laser, shock waves, or electrical energy to fragment the stone.
  • If the second doctor blames the first, that would be a huge help for the plaintiff.
Jurisdiction
  • Montgomery County
Defendants
  • Montgomery General Hospital, Inc.
  • Chesapeake Urology Associates, LLC
  • Chesapeake Urology Associates, P.A.
  • Two urologist in Montgomery County
Facilities Where Patient was Treated
  • Montgomery General Hospital, Inc.
  • Chesapeake Urology Associates, LLC
  • Chesapeake Urology Associates, P.A.
  • Johns Hopkins Hospital
Negligence

Key claims:

  • Failure to recognize that lithotripsy was the more appropriate procedure for stone removal for this patient, and take the steps necessary to timely arrange for lithotripsy
  • Failure to appreciate the risk of ureteral injury if the stone could not be easily and safely removed
  • Failure to place a ureteral stent after the initial procedure
  • Failure to safely utilize surgical tools, such as the stone basket
  • Failure to timely and adequately repair the ureteral mucosal injury
Specific Counts Pled
  • Economic damages
  • Noneconomic damages: physical pain and suffering, discomfort, and mental anguish, loss of enjoyment of life
  • Loss of consortium
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