A 42-year-old woman is evaluated in the hospital for fever, chills, and severe right-sided… — USMLE Step 3

A 42-year-old woman is evaluated in the hospital for fever, chills, and severe right-sided flank pain that began $12$ hours ago. She underwent a difficult laparoscopic total hysterectomy and bilateral salpingo-oophorectomy for severe endometriosis $4$ days ago. Her temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), blood pressure is $105/65$ mm Hg, pulse is $112$ /min, and respirations are $20$ /min. Physical examination reveals marked right costovertebral angle tenderness. Her abdomen is soft with well-healing laparoscopic incisions and mild bilateral lower quadrant tenderness. Laboratory studies show a leukocyte count of $18,500/\mu\text{L}$ and a serum creatinine level of $2.3$ mg/dL (baseline was $0.8$ mg/dL preoperatively). A bedside renal ultrasound demonstrates severe right-sided hydronephrosis with no left-sided abnormalities. Which of the following is the most appropriate next step in management?

Percutaneous nephrostomy tube placementAnswer
B
Cystoscopy with retrograde ureteral stenting
C
Immediate exploratory laparotomy for ureteral repair
D
Intravenous administration of broad-spectrum antibiotics and observation
E
Computed tomography of the abdomen and pelvis with intravenous contrast

Answer

Percutaneous nephrostomy tube placement

The correct answer is percutaneous nephrostomy tube placement. This patient presents with systemic inflammatory response syndrome (fever, tachycardia, leukocytosis), acute kidney injury, and right-sided hydronephrosis just four days after a complex pelvic surgery. This clinical picture is pathognomonic for an iatrogenic ureteral injury (e.g., ligation) resulting in an infected, obstructed kidney. This is a severe urologic emergency. Immediate source control via urinary decompression is mandatory to prevent progressive sepsis and permanent loss of renal parenchyma. In cases of acute post-operative ureteral injury where complete ligation or transection is highly probable, an antegrade percutaneous approach (nephrostomy tube) is the most reliable, effective, and safest method to establish drainage.

Step-by-Step Solution

Identify the primary clinical problem from the presentation.

The patient presents with the triad of fever, flank pain, and post-operative ipsilateral hydronephrosis, which is highly suspicious for an iatrogenic ureteral injury (ligation or thermal damage) leading to an infected, obstructed kidney.

Pelvic surgeries, especially complex hysterectomies for endometriosis, carry a high risk of distal ureteral injury.

Determine the urgency and therapeutic goal.

An infected, obstructed kidney is a urologic emergency that requires immediate urinary decompression to prevent irreversible renal damage and gram-negative sepsis.

Intravenous antibiotics cannot adequately penetrate an obstructed, purulent collecting system without mechanical drainage.

Select the most appropriate procedural intervention.

Percutaneous nephrostomy tube placement is chosen to provide antegrade drainage.

Because the obstruction is likely a complete ligation or transection near the pelvic brim, attempting retrograde access via cystoscopy has a high failure rate and risks further ureteral trauma.

Key Concept

Management of suspected infected hydronephrosis secondary to an acute iatrogenic ureteral injury requires emergent decompression, optimally via antegrade percutaneous nephrostomy, as retrograde stenting is likely to fail.

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