Medical Malpractice and Nephrolithiasis: U.S. Appellate Cases from 2001 to 2018.

INTRODUCTION: Kidney stones are one of the most litigated diagnoses in urological practice. To better understand the cause for and outcomes of medical malpractice cases related to nephrolithiasis we analyzed United States medical malpractice appeals court cases from 2001 to 2018. METHODS: We searched LexisNexis for "kidney stone/nephrolithiasis" and "malpractice" from 2001 to 2018. Individual case data were compiled and analyzed with descriptive statistics, including involved parties, outcome of the initial case/appeal, alleged physician negligence, monetary awards granted and size of awards. RESULTS: Our search yielded 45 cases, of which 33 met criteria for analysis. The patient/spouse was the plaintiff in 23/33 (69%) cases, and the patient's estate was the plaintiff in 10/33 (30%) cases. A urologist was a defendant in 19/33 (57%) cases and nonurological providers were named in 10/33 (30%) cases. A hospital was named in 21/33 (64%) lawsuits. A total of 30/33 (91%) suits cited an error in treatment as the primary negligence. Of all cases, 10% were reversed on appeal and the majority of cases were found in favor of the defendant initially and on appeal. Overall, the defendant prevailed in 21/33 (63%) of cases. Four trials involved payment to a plaintiff and the average payout was $1,075,439 (range $193,000-$3,000,000). CONCLUSIONS: The majority of nephrolithiasis malpractice suits involve a verdict in favor of the urologist, physician or hospital, even after appeal. Errors in treatment are much more commonly litigated than errors in diagnosis. Although the prevalence of plaintiff payout was low, awards granted averaged over a million dollars per case.

Pain Relief for Acute Urolithiasis: The Case for Non-Steroidal Anti-Inflammatory Drugs.

Pain from renal colic is often severe and incapacitating. Many patients require emergent hospitalization and aggressive analgesia to relieve such discomfort. For many years, the optimal analgesic strategy has been sought to manage such severe pain. One of the mainstays of therapy for acute renal colic is with non-steroidal anti-inflammatory drugs (NSAIDs). This paper reviews the mechanism by which NSAIDs allow pain relief in renal colic, the evidence for their use in this condition, and the use of NSAIDs combined with other agents in renal colic.

Failing to follow up: predicting patients that will "no-show" for medically advised imaging following endourologic stone surgery.

INTRODUCTION: The purpose of this study is to evaluate predictors of poor compliance after treatment of urinary stone disease. MATERIALS AND METHODS: This study was a retrospective analysis of patients who underwent stent removal following percutaneous nephrolithotomy (PCNL) or ureteroscopy (URS) between 2008-2012. All patients were scheduled for follow up evaluation and renal ultrasound at 4-6 weeks following stent removal. Patients were stratified based on appointment compliance and demographic variables including gender, age, insurance type (Government Assisted Insurance [GAI] or Private Insurance [PI]), initial procedure, season, distance between home and clinic, average monthly gas price at follow up, and median education attainment. Logistic regression was performed to determine independent predictors of missed follow up. RESULTS: A total of 301 patients were included, 153 women (51% female) with a mean age of 54 ± 14.2 years. Of the cohort, 22.6% (n = 68) did not return for follow up. GAI was the only variable associated with a greater risk of non-compliance on univariate analysis (OR 2.13 [95% CI 1.12-3.86] p = 0.011) and multivariate analysis (OR 3.14.10 [95% CI 1.48-6.7], p < 0.01). Gender, age, procedure, season, distance, gas prices, and education were not significant predictors. CONCLUSION: In our study, evaluating characteristics associated with missed follow up after stent removal for PCNL and URS, possession of GAI was the only factor associated with non-compliance. Urologists should be aware that persons with GAI may be at increased risk of missed follow up and should use this information to target interventions to improve compliance.

Robotic-assisted radical cystectomy: current technique and outcomes.

Robotic-assisted radical cystectomy continues to evolve as a surgical option in the management of muscle-invasive bladder cancer. Current oncologic outcomes appear comparable in the short-term with open radical cystectomy. Long-term follow-up, however, remains lacking for this emerging technique. Modern robotic technology allows a comparable extent of pelvic lymph node dissection as open surgery, a previous criticism of the procedure. Complications compare very favorably to open surgery in comparative series, and blood loss and transfusion rates are routinely lower. Length of stay has been shortened in some series, though not uniformly. Finally, robotic assistance can increase the cost of radical cystectomy.

Impact of repeated hilar clamping on renal function during laparoscopic and robot-assisted partial nephrectomy.

BACKGROUND AND PURPOSE: Conventional wisdom and small animal studies suggest repeated hilar clamping during partial nephrectomy is deleterious to renal function. We describe the impact of repeated renal hilar clamping during laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RPN) on the overall function of the operated kidney. PATIENTS AND METHODS: A retrospective analysis of all patients undergoing RPN or LPN with repeated hilar clamping was performed. Patient and tumor characteristics were recorded. All patients had preoperative and postoperative mercaptoacetyltriglycine (MAG)3 renal scans, and the change in function was calculated. Change in glomerular filtration rate (GFR) was calculated with the modified Modification of Diet in Renal Disease equation as well. RESULTS: Seven patients were studied with an average age of 60 and a body mass index of 32. Tumors averaged 3.6 cm, and there were four and three right- and left-sided tumors, respectively. The reasons for repeated clamping were bleeding in three patients and either gross or microscopic positive margins in four patients, all of whom had repeated resection. The average initial clamp time was 20 minutes, and the average reclamp time was 12 minutes. The average operative time was 185 minutes. and average blood loss was 171 mL. All renal units were functioning postoperatively. The average change in absolute renal function on the operated kidney was -4.9%, and the relative loss of function was -10%, both measured on MAG3 scan. The average GFR before surgery was 61.4 (mL/min/1.73m(2)); after surgery, the average GFR was 57.1 (mL/min/1.73m(2)), for an average loss of -7%. The range of change in GFR was from 0% to -23%. CONCLUSIONS: Although not optimal, repeated clamping of the renal hilum during partial nephrectomy to control bleeding or to obtain a clear surgical margin is associated with minimal loss of renal function.

Searching robotic prostatectomy online: what information is available?

OBJECTIVES: To search online using the Google search engine to determine what information for robotic-assisted radical prostatectomy (RARP) is available and whether the claims made on the Internet are supported by the published peer-reviewed urologic data. METHODS: The term "robotic prostatectomy" was searched using Google on September 29, 2009. The first 50 Web sites were reviewed for RARP specific outcomes, including oncologic outcomes, potency, continence, recovery, and blood loss. All claims were compared with the accepted standards supported by the existing published urologic data. RESULTS: Of the first 50 Web sites, 9 were rejected. Of the remaining 41, 29 were from academic practices and 8 from nonacademic practices; for 4, this distinction was not applicable. Also, 19 sites had direct links, photographs, or text from the Intuitive Surgical Web site, and 22 sites did not. Of the 41 Web sites, 20 made no mention of surgeon experience with RARP and 21 did, with an average experience of 1487 ± 1206 cases. More than 60% of the sites claimed better potency outcomes with RARP than with radical retropubic prostatectomy, although 32% of sites omitted this information. Similarly, 63% of the Web sites claimed improved continence with RARP than with radical retropubic prostatectomy, and 29% of the sites made no mention of continence. Data on oncologic efficacy was missing from 22% of the Web sites, 22% suggested the cancer outcomes were equivalent between RARP and radical retropubic prostatectomy, and 56% suggested the cancer outcomes were better with RARP. Concerning postoperative recovery and blood loss, 85% of the sites stated that both were improved with RARP, and only 15% omitted these data. CONCLUSIONS: Overall, an online search using the Google search engine for robotic prostatectomy yielded many Web sites with unsubstantiated information of variable accuracy.

The gatekeeper disparity--why do some medical schools send more medical students into urology?

PURPOSE: Urology continues to be a highly desirable specialty despite decreasing exposure of students to urology in American medical schools. We assessed how American medical schools compare to each other in regard to the number of students that each sends into urological training. We evaluated the reasons why some medical schools consistently send more students into urology than others. MATERIALS AND METHODS: We obtained American Urological Association Match data for the 5 match seasons from 2005 to 2009. We then surveyed all successful participants. The survey instrument was designed to determine what aspects of the medical school experience influenced students to specialize in urology. Bivariate and multivariate analysis was then done to assess which factors correlated with more students entering urology from a particular medical school. RESULTS: Between 2005 and 2009 a total of 1,149 medical students from 130 medical schools successfully participated in the urology match. Of the 132 allopathic medical schools 128 sent at least 1 student into urology (mean ± SD 8.9 ± 6.5, median 8). A few medical schools were remarkable outliers, sending significantly more students into urology than other institutions. Multivariate analysis revealed that a number of medical school related variables, including strong mentorship, medical school ranking and medical school size, correlated with more medical students entering urology. CONCLUSIONS: Some medical schools launch more urological careers than others. Although the reasons for these findings are multifactorial, recruitment of urological talent pivots on these realities.

A standardized pain management protocol improves timeliness of analgesia among emergency department patients with renal colic.

BACKGROUND: Kidney stones are a common, and extremely painful, cause of emergency department (ED) visits. Pain management is a critical component of high-quality patient care. A pilot study at our institution found that only 69% of ED patients with renal colic had evidence of clinically significant analgesia. OBJECTIVE: In response to these findings, we evaluated the impact of a formalized pain management protocol on timeliness of analgesia among ED patients with renal colic. SUBJECTS AND METHODS: Using a before and after study design, adult ED patients with renal colic were eligible. In the prospective arm, patients were treated with ketorolac, 30 mg intravenous, and morphine, 0.05-0.1 mg/kg intravenous, according to a standardized protocol. Results were compared with a retrospective chart review of eligible patients treated during a similar preprotocol period. RESULTS: Implementation of the protocol resulted in a significant reduction in time to effective analgesia (72 ± 63 vs 37 ± 42 minutes, P = .003). The protocol did not result in any increase in adverse effects. CONCLUSION: Implementation of a standardized pain management protocol among ED patients with renal colic resulted in a marked improvement in quality of care as evidenced by a 49% reduction in time to effective analgesia.

Adjuncts to improve outcomes of shock wave lithotripsy.

Shock wave lithotripsy (SWL) has been a major tool in the treatment of urinary stones for nearly three decades. In recent years, SWL technology has been less effective at fragmenting stones than earlier devices; thus, adjunctive maneuvers to improve stone-free rates after SWL have been required. This article summarizes several of these adjuncts, such as slower shock wave rate, the use of percussion therapy to clear fragments, medications to hasten expulsion of fragments, and appropriate selection and positioning of patients for SWL.