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Difficulty: MediumUrologic Surgery

A 5555-year-old woman is brought to the emergency department due to severe right flank pain, fever, and chills for the past 2424 hours. Her temperature is 39.2∘C39.2^\circ\text{C} (102.6∘F102.6^\circ\text{F}), blood pressure is 88/55 mm Hg88/55\text{ mm Hg}, and pulse is 122/min122/\text{min}. Laboratory studies show a leukocyte count of 18,000/mm318,000/\text{mm}^3. A noncontrast computed tomography scan of the abdomen and pelvis reveals a 9-mm9\text{-mm} obstructing calculus in the right proximal ureter with moderate hydronephrosis and perinephric stranding. Arrange the following management steps in the most appropriate chronological order.

  1. 1Administer intravenous fluids and empiric broad-spectrum antibiotics
  2. 2Perform urgent percutaneous nephrostomy or placement of a ureteral stent
  3. 3Monitor the patient and continue antimicrobial therapy until sepsis resolves
  4. 4Perform definitive stone removal via ureteroscopy or shock wave lithotripsy

Answer

The correct sequence is to first resuscitate the patient with intravenous fluids and antibiotics, then urgently decompress the collecting system via nephrostomy or stenting, followed by continued monitoring until the sepsis resolves, and finally proceeding with delayed definitive stone removal.
An infected obstructing ureteral stone is a severe urologic emergency. The sequence of management strictly follows the principles of sepsis care and source control: first, medical resuscitation (intravenous fluids and broad-spectrum antibiotics) is initiated to stabilize the patient. Next, urgent minimal-intervention decompression (via percutaneous nephrostomy or ureteral stent) is performed to drain the infected urine. The patient is then stabilized on continued antibiotics. Only after the systemic infection has completely resolved is it safe to proceed with delayed, definitive surgical removal of the stone, as high-pressure irrigation during acute infection can exacerbate sepsis.

Step-by-Step Solution

1
Administer intravenous fluids and empiric broad-spectrum antibiotics.
The patient's intravascular volume is restored, and antimicrobial therapy is initiated against the presumed uropathogens.
Sepsis from an infected urolithiasis is a life-threatening emergency requiring immediate medical stabilization before any surgical intervention.
2
Perform urgent decompression of the collecting system (e.g., percutaneous nephrostomy).
The purulent urine is drained from the obstructed renal pelvis, controlling the source of infection.
Antibiotics alone cannot penetrate an obstructed, infected system effectively; physical decompression is mandatory for source control.
3
Continue monitoring and antimicrobial therapy.
The systemic inflammatory response syndrome resolves, and the patient becomes hemodynamically stable.
Time is needed for the infection to clear and for the patient to optimize their physiological state prior to definitive surgery.
4
Perform definitive stone removal.
The obstructing 9-mm9\text{-mm} calculus is fragmented and extracted.
Definitive lithotripsy or ureteroscopy is highly risky in an infected system due to the risk of exacerbating sepsis. It is performed safely as a delayed procedure.

Key Concept

Sequential management of an infected obstructing ureteral stone (urologic emergency)
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Topics

Urologic Surgery

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