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Difficulty: MediumUrologic Surgery

A 48-year-old woman is evaluated for right-sided flank pain and nausea on postoperative day 2 following a total abdominal hysterectomy for symptomatic uterine leiomyomata. She reports the pain is constant and severe. Her temperature is 37.7∘C37.7^\circ\text{C} (99.9∘F99.9^\circ\text{F}), blood pressure is 128/78 mm Hg128/78\text{ mm Hg}, and pulse is 86/min86/\text{min}. Physical examination reveals exquisite right costovertebral angle tenderness. The surgical incision is clean, dry, and intact without erythema or induration. Laboratory results are as follows:

Blood urea nitrogen: 28 mg/dL28\text{ mg/dL}
Serum creatinine: 1.8 mg/dL1.8\text{ mg/dL} (baseline: 0.8 mg/dL0.8\text{ mg/dL})

Urinalysis:
Leukocyte esterase: negative
Nitrites: negative
WBC: 1−2/hpf1-2/\text{hpf}
RBC: 10−15/hpf10-15/\text{hpf}

Renal ultrasonography demonstrates moderate right-sided hydronephrosis. The left kidney appears normal. Which of the following is the most appropriate next step in management?

  1. Cystoscopy with retrograde pyelographyAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Immediate exploratory laparotomy
  4. D
    Intravenous broad-spectrum antibiotics
  5. E
    Reassurance and repeat renal ultrasonography in 24 hours

Answer

Cystoscopy with retrograde pyelography
The patient's presentation of unilateral flank pain, acute kidney injury, and hydronephrosis shortly after a pelvic surgery (total abdominal hysterectomy) is highly suspicious for an iatrogenic ureteral injury, such as accidental ligation or kinking of the right ureter. The ureters are particularly vulnerable where they cross under the uterine artery. The most appropriate next step is cystoscopy with retrograde pyelography. This procedure uses locally instilled contrast (which avoids the risk of systemic contrast-induced nephropathy) to precisely identify the location and nature of the ureteral obstruction. Additionally, it allows for a simultaneous therapeutic attempt to pass a ureteral stent to relieve the obstruction and decompress the kidney.

Step-by-Step Solution

1
Identify the primary clinical problem.
The patient has acute, unilateral right-sided hydronephrosis and acute kidney injury (creatinine elevated to 1.8 mg/dL1.8\text{ mg/dL}) two days after pelvic surgery.
Recognizing the temporal relationship between a total abdominal hysterectomy and new-onset hydronephrosis points toward an iatrogenic ureteral injury.
2
Evaluate the patient's stability and laboratory contraindications.
The patient is hemodynamically stable, afebrile, and does not have a urinary tract infection. However, she has acute kidney injury.
The presence of acute kidney injury strictly contraindicates imaging modalities that require systemic nephrotoxic agents, such as intravenous contrast.
3
Select the most appropriate diagnostic and therapeutic intervention.
Cystoscopy with retrograde pyelography is chosen.
It allows direct visualization of the ureter using locally instilled contrast (avoiding systemic nephrotoxicity) and offers the opportunity to pass a ureteral stent to decompress the kidney.

Key Concept

Iatrogenic Ureteral Injury Management
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Topics

Urologic Surgery

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