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Difficulty: MediumUrologic Surgery

A 52-year-old woman is evaluated in the emergency department for a 2-day history of severe left-sided flank pain, nausea, and chills. Her temperature is 39.4°C (102.9°F), pulse is 118/min, and blood pressure is 88/56 mm Hg. Physical examination reveals marked left costovertebral angle tenderness and voluntary guarding. Laboratory studies show a leukocyte count of 18,500/mm318,500/\text{mm}^3 and a serum creatinine of 1.9 mg/dL1.9 \text{ mg/dL} (baseline 0.9 mg/dL0.9 \text{ mg/dL}). A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an 8-mm calculus in the proximal left ureter with ipsilateral hydronephrosis and prominent perinephric fat stranding. Intravenous fluid resuscitation and empiric broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in management?

  1. Placement of a percutaneous nephrostomy tubeAnswer
  2. B
    Continued observation with intravenous antibiotic therapy
  3. C
    Extracorporeal shock wave lithotripsy
  4. D
    Ureteroscopy with laser lithotripsy
  5. E
    Open pyelolithotomy

Answer

Placement of a percutaneous nephrostomy tube
This patient has an obstructing ureteral calculus complicated by urinary tract infection, resulting in obstructive pyelonephritis and septic shock (evidenced by fever, hypotension, and marked leukocytosis). An infected, obstructed kidney acts as a closed-space infection and represents a true urologic emergency. The most appropriate next step after initiating fluid resuscitation and broad-spectrum antibiotics is urgent decompression of the collecting system. This is typically achieved with either placement of a percutaneous nephrostomy tube or retrograde ureteral stenting. Definitive stone management must be delayed until the patient is hemodynamically stable and the infection has been completely eradicated.

Step-by-Step Solution

1
Analyze the patient's clinical and radiologic presentation.
The patient has fever, hypotension, leukocytosis, and an obstructing 8-mm proximal ureteral calculus.
These findings are diagnostic of obstructive pyelonephritis with early septic shock.
2
Determine the pathophysiological requirement for treatment.
The infected, obstructed collecting system functions as an undrained abscess.
Systemic antibiotics and fluid resuscitation are necessary but insufficient without mechanical source control.
3
Select the appropriate surgical intervention.
Urgent collecting system decompression via percutaneous nephrostomy tube or retrograde ureteral stenting is required.
Decompression relieves the pressure, allows infected urine to drain, and stabilizes the patient so definitive stone management can be safely performed at a later date.

Key Concept

Obstructive pyelonephritis is a urologic emergency that requires prompt decompression of the collecting system (via percutaneous nephrostomy or ureteral stenting) in addition to broad-spectrum antibiotics and fluid resuscitation.
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Topics

Urologic Surgery

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