As a urologist, this is one of my worst fears and something that I have had nightmares of.

As a surgeon who performs this operation on a regular basis, a few points should be mentioned.

1) I have never operated on a kidney without reviewing the films myself and having them in the operating room.

2) At 4 cm, this tumor may have been amenable to removing part of the kidney, making it even more important to review the films.

3) The patient should still have a reasonable chance at having someone remove just part of the kidney and then not needing dialysis.

4) We also use the preoperative pen marking in the US and this doesn't help this type of problem. My suggestion would be not to have a surgery if the films aren't in the room.