A smooth, metallic-looking structure sat inside a swollen chamber of a patient's kidney, right where a referring surgeon's notes said leftover hardware would be. The team began following it. About 3 centimeters later, doubt set in, and a closer look revealed the truth: the suspected foreign body was the shaft of the flexible scope the team was using, bent back on itself and swung into its own camera's view.
The near miss is described in a case report published online Aug. 25 in Diagnosis, a peer-reviewed journal focused on how and why diagnoses go wrong. The authors, İbrahim Üntan of the urology department at Ahi Evran University School of Medicine in Kırşehir, Türkiye, and Sultan Üntan, present it less as an equipment story than as a lesson in how expectation can overrule the eyes.
