Think of the forgotten stent primarily as a patient safety issue, writes Robert A. Dowling, MD.
Hippocrates wrote, “The physician must be able to tell the antecedents, know the present, and foretell the future—must mediate these things and have 2 special objects in view with regard to disease: namely, to do good or to do no harm.”
He wrote these words in the fifth century BC, and the modern interpretation of the phrase—“First, do no harm”—is that physicians should recommend tests or treatments for which the potential benefits outweigh the risks of harm.
Creating a culture of patient safety takes this concept further: Physicians arguably should recognize serious safety risks—even if they are uncommon—and stringently practice the behaviors that prevent harm to patients. For example, a surgical time-out prevents wrong-site surgery, 2 patient identifiers on a specimen label prevent most labeling errors, and high-level disinfection or sterilization of instruments prevents patient-to-patient transmission of bacteria, fungi, and viruses.
To prevent these harms, these behaviors must become ingrained, habitual, part of our culture, and practiced 100% of the time. In a urology practice, harms may occur because the simple behaviors known to reduce or prevent some harms are not practiced each and every time. The culture of safety is still evolving, and events may seem so rare that it feels like “overkill” to expend energy on prevention.
In this article, I will examine prevention strategies for one of those harms that should resonate with most urologists—the forgotten ureteral stent.
It is indisputable that a retained ureteral stent can and does cause harm. That harm can result from encrustation, infection, obstruction, or complications from the treatment of these preventable problems. That harm can include loss of a kidney or death.1 How often does this harm occur? Estimates show that 1.5% to 12.5% of stenting procedures result in a forgotten stent in the modern era.2
Urologists perform stent insertions hundreds of times in their careers, so even if the incidence is “only” 1%, every urologist has patients at serious risk for this preventable harm. Most urologists have seen patients with retained stents, even if they did not perform the original surgery. This is not a rare event, it can be life threatening, and it is largely preventable.
Many patients with a forgotten ureteral stent are labeled “noncompliant”; this label implies they knew they had a stent, fully understood the consequences of not having it removed, and chose to harm themselves.
What are the actual factors that lead to a retained stent and its complications? Lack of insurance or access to care is a common reason but not the only reason cited by patients with forgotten stents.3 Other patients report forgetting about the stent or never knowing they had a stent or needed follow-up. Patients at higher risk of a forgotten stent include those who are male sex, ethnic minorities, unemployed, and non–English speaking.4
There are also physician and practice risk factors. Many patients at risk for retained stents are seen emergently outside the office and undergo unscheduled surgery. These patients may escape preoperative registration with the practice and some of the safeguards that come with office policies. The only opportunity to confirm contact information and arrange follow-up might depend upon the physician.
Poor communication, delayed charge posting, incomplete record keeping, and inconsistent patient engagement are potential risk factors in the treating physician or practice. Some patients with chronic ureteral stents undergo periodic stent exchanges—this is a risk factor, as is the common practice of relying on the patient to initiate contact in a few months for their exchange.
Although some of these factors cannot be controlled, recognizing them is an important part of a strategy to prevent harm from the forgotten stent.
What behaviors can prevent a retained stent and its attendant harms? What follows are my 6 suggestions for behaviors to practice each time, every time a stent is inserted:
1. Affix a hospital-style wristband (available from your facility or on Amazon for less than 15 cents apiece) with the date of anticipated stent removal to the patient’s wrist; the band is not to be removed until the stent is removed. If the patient speaks limited English, inform and apply the wristband in their preferred language. Patients with chronic stent exchanges may use a medical alert silicone version of the wristband.
2. Verify the telephone number of the patient or their emergency contact by calling the number from the facility phone before the patient is discharged.
3. For patients with a tether who are instructed in self-removal, give the patient a return form stating, “I removed my ureteral stent on (date),” along with a preaddressed (to your practice) stamped envelope. The form can include a picture of a stent so patients know it was removed in its entirety.
4. Schedule follow-up appointments before patients are discharged from the facility. A patient without insurance may refuse to schedule, may transfer their care, or may not keep their appointment; or they may keep their appointment, register with your practice, and pay their bill eventually. In any case, a retained stent is best prevented by having that follow-up conversation before you potentially lose contact with the patient. As long as they have an internal foreign body, it is a safety issue, not a financial issue. Do not rely on the patient to initiate the appointment. At the earlier of either surgery documentation in the electronic health record or charge posting in the practice management system, set a chart alert in the system that reads, “PATIENT HAS INDWELLING STENT.” Remove the alert only when removal is documented.
5. Track every stent insertion and removal. This can be a manual process (ie, a registry), a software-assisted reminder or patient engagement tool,2 or a data-driven analysis. The process should include the stent insertion date, the documented stent removal date, and a method for contacting patients with removals that are overdue or not recorded. If your process occurs outside the medical record, be sure to document removal in the record. Think of this like a sponge count—the case isn’t complete until you have verified there isn’t a foreign body left in the patient. You don’t do a sponge count in 98% of open or vaginal cases; you do it in all cases to prevent the rare complication (gossypiboma) from a retained foreign body.
6. Make reasonable efforts to contact those patients who have stent removal that is undocumented or overdue. This includes phone calls, portal messages, emergency contacts, and certified letters. When it comes to a stent, no news is never good news.
The bottom line and why it matters: Retained ureteral stents are commonly thought of as a patient compliance issue, out of the physician’s control, or a malpractice risk for the urologist. Although they can be all of these, I would encourage you to think of the forgotten stent primarily as a patient safety issue—an avoidable bad outcome.
Become a safety enthusiast. Using a safety paradigm may help you reduce or even eliminate this problem in your practice. As Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure.”
1.Adanur S, Ozkaya F. Challenges in treatment and diagnosis of forgotten/encrusted double-J ureteral stents: the largest single-center experience. Ren Fail. 2016;38(6):920-926. doi:10.3109/0886022X.2016.1172928
2. Krishna S, Abello A, Steinberg P. Forget forgotten stents: review of ureteral stent tracking systems. Urol Pract. 2021;8(6):645-648. doi:10.1097/UPJ.0000000000000265
3. Weedin JW, Coburn M, Link RE. The impact of proximal stone burden on the management of encrusted and retained ureteral stents. J Urol. 2011;185(2):542-547. doi:10.1016/j.juro.2010.09.085
4. Divakaruni N, Palmer CJ, Tek P, et al. Forgotten ureteral stents: who’s at risk? J Endourol. 2013;27(8):1051-1054. doi:10.1089/end.2012.0754