Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. I. Surgical Never Events: 2. Intracorporeally-Retained Urological Surgical Items

Abstract

Objective: Presentation of our center's experience in the management of intracorporeally-retained urological surgical items. Materials and Methods: Retrospective search of our center's data for cases of retained surgical items during the period July 2006 to June 2016. Each case was studied for the demographic and clinical variables including types, presentation, and management. Results: Out of more than 55,000 different urological interventions, only 39 cases (28 males and 11 females) had retained surgical items. Urolithiasis-related urological subspecialties were more involved than others. Forgotten items and technically-retained items occurred in 38.5 and 61.5% of cases, respectively, and were immediately discovered or discovered up to 10 years later. Material types were textiles, biosynthetics, and metallics in 31, 51, and 18%, respectively. Possible predisposing factors included complex surgeries, emergent intraoperative events, and extra approaches. Occurrences of retained surgical items before and after implemented corrective actions were 74.6 and 25.4%, respectively. All the final outcomes were either short- or long-term harm without deaths, organ losses, or permanent disabilities. Conclusion: Retained urological surgical items are surgical never events that result from forgetfulness or technical surgical human errors. Their sequels can be potentially fatal, but they are preventable and can be significantly reduced.