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Unplanned delayed removal of ureteric stents


The national investigation

This investigation relates to patients with kidney stones who have had a ureteric stent inserted and where the stent is left in longer than planned.

A ureteric stent is a thin plastic tube that’s inserted into the ureter (the tube that connects the kidney to the bladder). Stents help urine to drain from the kidney into the bladder by keeping the ureter open. They are inserted to help treat a range of conditions including kidney stones. Blockages caused by kidney stones and stones in the ureter (ureteric stones) are treated by breaking up the stone. Stents are used to help stone fragments drain away after treatment.

Ureteric stents are usually left in place for between a few days and three months, depending on why one has been inserted. When planning how long to leave the stent in place, the risk of the stent becoming blocked is considered, as they can become encrusted with the same deposits that form kidney stones.

Reference event

The reference event in this investigation is the case of a 77-year old woman. She suffered an episode of kidney stones that required the insertion of a ureteric stent after having a procedure to remove the stone. The stent was left in position for longer than intended and became encrusted. This meant she needed a more extensive operation to remove the stent.

Investigation summary

The investigation was launched after concerns were reported to HSIB by a senior consultant urologist at a large hospital with a specialist kidney stone service. They reported an increase in referrals for patients needing surgical removal of encrusted stents, due to delays in the routine removal of their ureteric stents.

This investigation:

  • Looks at how ureteric stents are tracked following insertion.
  • Examines patient communication strategies.
  • Explores the reasons for delays in stent removal.
  • Reviews published clinical practice.

The findings and conclusions aim to prevent the future occurrence of unplanned delayed removal of stents and improve care for patients across the NHS.