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Difficulty: HardUrologic Surgery

A rapid response is called for a 6565-year-old man on the medical ward due to acute hemodynamic deterioration. Two days prior, he was admitted for severe right flank pain. A non-contrast computed tomography (CT) scan at admission demonstrated a 99-mm calculus in the proximal right ureter with moderate hydroureteronephrosis. At that time, he was afebrile and hemodynamically stable. A urine culture was obtained, and he was started on intravenous normal saline and empirical ceftriaxone.

Currently, his temperature is 39.6∘C39.6^\circ\text{C} (103.3∘F103.3^\circ\text{F}), blood pressure is 82/5082/50 mm Hg, and pulse is 128128/min. He is lethargic, diaphoretic, and minimally responsive. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory studies show a leukocyte count of 22,000/mm322,000/\text{mm}^3 with 15%15\% bandemia. The admission urine culture has just resulted, demonstrating >105>10^5 CFU/mL of *Escherichia coli*. Susceptibility testing indicates the organism is sensitive to cefazolin, ceftriaxone, and ciprofloxacin, but resistant to ampicillin. He is receiving aggressive intravenous fluid resuscitation.

Which of the following is the most appropriate next step in management?

  1. Placement of a percutaneous nephrostomy tubeAnswer
  2. B
    Escalate antibiotic therapy to intravenous meropenem
  3. C
    Retrograde ureteroscopic stone extraction
  4. D
    Contrast-enhanced CT scan of the abdomen and pelvis
  5. E
    Continued observation with aggressive medical management

Answer

The most appropriate next step is the immediate placement of a percutaneous nephrostomy tube to decompress the infected, obstructed renal collecting system.
The patient is in septic shock secondary to an obstructing ureteral calculus (obstructive pyelonephritis). This represents a true urologic emergency. When infected urine is trapped under high pressure behind an obstruction, bacteria and inflammatory mediators rapidly translocate into the renal venous and lymphatic systems. Medical management (intravenous fluids and targeted antibiotics) is crucial but fundamentally insufficient without mechanical source control. The collecting system must be immediately decompressed. In a hemodynamically unstable patient, placement of a percutaneous nephrostomy (PCN) tube under local anesthesia by interventional radiology is typically the safest and most effective definitive next step, as it avoids the systemic vasodilation and cardiac depression associated with the general anesthesia required for retrograde ureteral stenting.

Step-by-Step Solution

1
Analyze the patient's acute clinical deterioration.
The patient has developed high fever, hypotension, tachycardia, altered mental status, and marked leukocytosis with bandemia.
These findings fulfill the criteria for septic shock, indicating a life-threatening systemic response to infection.
2
Identify the source of the infection based on history and physical exam.
The patient has a known 99-mm obstructing right ureteral stone and right costovertebral angle tenderness, alongside an *E. coli* positive urine culture.
This confirms the diagnosis of obstructive pyelonephritis, a closed-space infection of the upper urinary tract.
3
Determine the required intervention for an infected, obstructed urinary system.
Immediate mechanical decompression via percutaneous nephrostomy (PCN) or a retrograde ureteral stent is required.
Systemic antibiotics cannot effectively penetrate an obstructed, high-pressure infected kidney. Source control via surgical decompression is mandatory to prevent mortality.

Key Concept

Obstructive pyelonephritis complicated by sepsis is a urologic emergency requiring immediate mechanical decompression of the collecting system (e.g., percutaneous nephrostomy or ureteral stent) in addition to antibiotics and hemodynamic resuscitation.
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Urologic Surgery

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