A case of fatal embolization during laser lithotripsy

Purpose: To report in literature the first case of fatal multi-organ embolization of ureteral stones fragments during laser lithotripsy. Case presentation: A tetraplegic 43-year-old woman was admitted to the hospital to undergo laser lithotripsy because of bilateral ureteral stones and right ureteral infected stent. During the removal of the right ureteral stent, the patient developed a sudden severe bradycardia followed by a reduction in the arterial oxygen saturation. In spite of a rapid and intensive medical intervention, the clinical picture did not improve; the woman was therefore transferred to the nearest Emergency Room where she was rescued but a cardiocirculatory arrest occurred. A claim of alleged medical malpractice was brought against the urologists. A complete autopsy was performed 8 days after death. Autopsy findings: The diagnosis was determined by the microscopic findings: they have unequivocally shown a massive embolization of calculus fragments in the lungs and in the heart. In the light of all these findings, the cause of death was attributable to a disseminated intravascular coagulation due to this unforeseeable embolization of calcified amorphous material. Conclusion: Embolization of calculus fragments represents an important challenge because it is extremely unpredictable. Indeed, a prompt diagnosis of non-thrombotic pulmonary embolism, during the urologic procedure, is extremely difficult because the condition presents with no specific clinical signs: this life-threatening pathology is often underestimated. For this reason, the autopsy and the subsequent histopathological examination are indispensable in order to prove lethal embolization: microscopic findings play a key role in the final diagnosis of death.