ArticlePatient safety in surgery2026
Extensive perinephric hematoma following excessive irrigation pressure during flexible ureteroscopy: case report of a preventable complication.
Article in Patient safety in surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundFlexible ureteroscopy (fURS) is widely regarded as a safe and effective procedure for the management of urolithiasis. Nevertheless, inadequate management of intrarenal pressure during fURS represents an underrecognized patient safety hazard. The use of high-pressure irrigation to compensate for poor visualization—particularly when outflow is restricted—may expose patients to prolonged supraphysiologic intrarenal pressure and preventable harm. I report a severe pressure-related renal injury following fURS and analyze the event using a human factors and systems-based root cause analysis framework. CASE PRESENTATION: A 45-year-old man underwent fURS for a 1.5-cm proximal ureteral stone. A ureteral access sheath was not used due to a tight distal ureter. During the 100-min procedure, visualization progressively deteriorated because of mucosal edema, bleeding, and debris. Irrigation was escalated using a manual pressure bag and reported intraoperatively as very high (300–400 mmHg on the pressure bag gauge) for a prolonged period. Shortly following surgery, the patient developed severe flank pain and a high-grade fever. Computed tomography revealed a massive perinephric hematoma without active contrast extravasation. The patient remained hemodynamically stable and improved with conservative management.
conclusionThe described event is best understood as a preventable iatrogenic injury arising from a predictable hazard: pressure escalation to restore visualization. It occurred in a system without adequate defenses, namely, limited outflow, a lack of real-time pressure feedback, the absence of pressure or time stop rules, and insufficient team cross-checks against cognitive fixation. Intrarenal pressure should be treated as a critical safety variable in endourology. Pressure-governed workflows—prioritizing outflow augmentation, objective monitoring when feasible, and escalation pathways that favor staging over unmonitored pressure escalation—are essential to prevent similar harm.
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