The patient, born in 1950, started treating with a Florida urologist in 2016. At that time, the patient reported a remote history of bladder cancer, diagnosed around 2000, with a recurrence around 2005 -- all in New York where he used to live. The patient had undergone TURBT and 2 rounds of BCG at various times. The patient also had a history of enlarged prostate and chronic prostatitis, for which he took daily macrobid.
The patient saw the Florida urologist regularly, with annual cystoscopies, which were always negative. There were also various episodes of hematuria over the years, diagnosed as cystitis and treated with other antibiotics. The patient's prostate-related symptoms got worse, and in late 2020 the urologist was planning to do a TURBT.
On 12/28/2020, the urologist saw the patient and diagnosed recurrent bacterial prostatitis, for which he prescribed doxycycline. The following day, the patient went to the emergency department complaining of a UTI, confusion, and body aches. A CT of the abdomen and pelvis showed diffuse bladder wall thickening with mucosal hyperenhancement, compatible with cystitis, along with a mildly enlarged prostate. The CT report "Impression" also stated: "Focal urothelial thickening and enhancement of the proximal right ureter, versus prominent periureteral blood vessel. Mild fullness of right renal collecting system compared to the left, however no significant hydroneprhosis. Consider follow-up CT urogram in 3-6 months."
The patient was admitted to the hospital from 12/29/2020 to 1/4/2021, diagnosed with acute encephalopathy due to AKI and possible sepsis, cystitis and prostatitis with ESBL E. coli, and BPH with obstructive uropathy. His regular treating urologist saw him in consultation in the hospital on 12/31/2020. The consult note says, in pertinent part, "CT scan and labs are all consistent with severe cystitis.... I reviewed his CT scan and still feel that TURP is indicated."
The urologist did go on to do a TURP several weeks later, and continued to see the patient regularly, but never did a CT urogram as recommended or got other imaging to follow up on the ureteral thickening. In May 2021, he noted microhematuria on an office visit, and sent the patient's urine for cytology, which was later noted to have been negative, although we have been unable to confirm that with an actual lab report.
On 10/21/2022, the patient's treating pulmonologist (who saw him for COPD and a history of cryptogenic organizing PNA) ordered a CT chest. The CT report described moderate to severe right hydronephrosis, which had not been present on the previous study in 7/2020. The urologist ordered a CT abdomen & pelvis 11/7/2022, which confirmed moderate to severe right hydronephrosis, and a filling defect in the midsection of the right ureter; a tumor could not be excluded. A ureteroscopy and biopsy were done, and the biopsy results showed high-grade transitional cell carcinoma of the ureter.
The patient had the kidney and ureter removed on 12/28/2022, and in March 2023, a new urologist cauterized a small recurrence of the TCCA in the patient's bladder.
The patient does not know if his cancer has been staged, but knows there is a plan for chemotherapy.
I am interested not only in knowing whether the urologist should have done more to follow up on the 12/2020 CT findings, but also whether it likely made a difference to the patient's eventual outcome -- particularly to his survival chances.
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Q: Hi, for some reason, it doesn't allow me to submit my answers. Can you help?
A: —
Do you believe there might have been medical error?
Clearly a missed case of TCC There should have been additional follow up Repeat CY should have been done
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There should have been a degree of suspicion given prior hx of TCc Perhaps if seen earlier he could have had a local resection
What makes you a good expert for this case?
Practicing urologist for 30 years Extensive endoscopic experience Excellent record with malpractice review
How often do you encounter cases similar to this one in your practice?
10-12 yearly for 30 years. Ureterla thickening is commonly evaluated
Do you believe there might have been medical error?
Without looking at the original images, it is difficult to say truly if there was a process going on in the right ureter. Sometimes when looking at the images, our suspicion does either go up or go down. The fact that he had a subsequent urine cytology was negative, would be comforting to the urologist and allow him to perceive that whatever the condition that was seen on the CT is a benign one. Of course, it could be low-grade at that time and not show up on cytology. Overall I think it would be unlikely for this patient to keep his kidney and ureter. Sometimes we are able to introduce chemotherapy into the ureter itself, especially in lower grade tumors of the ureter however, in this case, it sounds like he was going to end up with a nephroureterectomy either way. If this patient has metastatic disease or nodal disease, then he would have a case that the delay lead to a worsening outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I would only say that his outcome would be worse if indeed, he had metastatic disease. Then the delay in diagnosis certainly lead to a worsening outcome. Either way, I think his kidney and ureter would be coming out as there are limited treatments for ureteral tumors.
What makes you a good expert for this case?
I am a board-certified urologist, and in my community I do both run our urology tumor board and perform major open surgery.
How often do you encounter cases similar to this one in your practice?
I see cases of ureteral or renal pelvic tumors probably 2 to 3 times annually.
Do you believe there might have been medical error?
Should have had a follow up ct in 6 months. If discovered earlier would have been easier to treat and better prognosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had the ct been done earlier, mass would have been smaller and easier to treat
What makes you a good expert for this case?
Vast career and enormous experience
How often do you encounter cases similar to this one in your practice?
Sometimes Many urologists are in a hurry to do obvious surgeries
Do you believe there might have been medical error?
It is not clear if the original CT scan done while the patient was in the hospital was ordered by the consultant urologist or another physician. In situations like this, the physician who orders the CT scan is usually responsible for arranging any follow-up studies. Or at the least, the ordering physician should document that any unanswered questions on the study have been reviewed with the consultant and therefore follow-up to be arranged by the consultant thereafter. In this case, we did not have that type of documentation presented. Therefore, it is not clearly evident which physician would be responsible for arranging any follow-up studies. Having said that, it is not uncommon to see some degree of pelviectasis or fullness of the renal pelvis during urinary tract infection, especially in a patient who's borderline septic. The radiologist recommended consideration for a follow-up CT urogram in 3 to 6 months so this can be interpreted as only a recommendation for follow-up.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
On the original CT scan in 2020, when the patient was hospitalized during an acute infection, the CT identified very subtle non-specific abnormalities involving the urothelial wall thickening and mild renal pelviectasis. Taken together, these are not clinically significant abnormalities to warrant any immediate action, but I would agree that a follow-up CT urogram may have been strongly considered for follow-up. Or at least, an ultrasound examination of the kidney. However, collectively, these mild abnormalities identified on the CT scan are non-specific and therefore cannot be deemed as causative for the patient's future outcome with any degree of certainty.
What makes you a good expert for this case?
Board certified urologist with fellowship training in endourology
How often do you encounter cases similar to this one in your practice?
In my current practice, I am frequently consulted for inpatients treated for acute urologic infections. Many, if not all of these patients obtain imaging studies which oftentimes identify multiple incidental findings. As a consultant, sometimes it is very confusing which physician will be responsible for arranging for follow-up of these incidental abnormalities. In my practice, if any urologic incidental abnormalities are identified, I take it upon myself to arrange for follow-up and document this in the patient's medical record so that other physicians are not arranging for unnecessary duplicate evaluation
Do you believe there might have been medical error?
Would need to review pathology report and radiology in detail first.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there was no metastatic disease, then there has likely not been any long term injury beyond that caused by the initial disease (cancer).
What makes you a good expert for this case?
I am a board certified urologist.
How often do you encounter cases similar to this one in your practice?
Often enough. Following up on imaging is a key to providing the best care for patients.
Do you believe there might have been medical error?
A diagnosis of upper tract TCC may have been made earlier if repeat CT urogram was performed. Without knowing the details of the case, there may have been many medical and/or social reasons that could have lead to the urologist NOT having done a CT urogram earlier.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While an earlier diagnosis could have been made, it is not certain that the prognosis would have been impacted. I need to know the grade and stage of the tumor and margin and lymph node status of the final specimen.
What makes you a good expert for this case?
I am a board certified urologist focusing on ur0-oncology and have treated hundreds of patients with urothelial carcinoma. I have published over 65 articles in uro-oncology and I have been an investigator on dozens of clinical trials for urothelial carcinoma. I have experience being an expert witness.
How often do you encounter cases similar to this one in your practice?
I treat 150-200 patients per year with urothelial carcinoma including 20-30 patients per year with upper tract urothelial carcinoma.
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