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Zorluk: OrtaUrologic Surgery

An emergency medical services team brings a 6262-year-old female to the hospital due to excruciating right-sided back pain, rigors, and altered mental status that began 2424 hours ago. Her medical history includes multiple previous episodes of kidney stones. She visited an outpatient clinic 4848 hours prior for pain on urination, where empirical oral nitrofurantoin was prescribed and a urine culture was obtained. Upon arrival today, vital signs show a temperature of 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F}), blood pressure of 85/55 mm Hg85/55\text{ mm Hg}, heart rate of 124/min124/\text{min}, and respiratory rate of 22/min22/\text{min}. Physical examination is notable for profound right costovertebral angle tenderness and dry mucous membranes. Blood tests indicate a leukocyte count of 22,000/mm322,000/\text{mm}^3. A non-contrast computed tomography scan reveals an 11-mm11\text{-mm} stone lodged in the proximal right ureter causing pronounced hydronephrosis. The outpatient clinic faxes her urine culture results, confirming an infection with Escherichia coli (>100,000 CFU/mL>100,000\text{ CFU/mL}). The organism is susceptible to ceftriaxone and ciprofloxacin, but resistant to ampicillin and nitrofurantoin. Rapid intravenous fluid resuscitation is commenced. Which of the following is the most appropriate next step in management?

  1. Percutaneous nephrostomy and intravenous ceftriaxoneCevap
  2. B
    Percutaneous nephrostomy and intravenous piperacillin-tazobactam
  3. C
    Intravenous ceftriaxone and observation
  4. D
    Extracorporeal shock wave lithotripsy and intravenous ceftriaxone
  5. E
    Ureteroscopic stone extraction and intravenous ceftriaxone

Cevap

Percutaneous nephrostomy and intravenous ceftriaxone
The correct answer combines urgent decompression with targeted antibiotic therapy. This patient presents with an infected, obstructing ureteral stone and resulting septic shock, which is a life-threatening urologic emergency. Immediate urinary tract decompression is mandatory to establish source control. This is typically achieved via percutaneous nephrostomy tube placement or retrograde ureteral stenting. Concurrently, antibiotic therapy must be optimized. Because the outpatient urine culture sensitivities are already available, transitioning to a targeted agent like intravenous ceftriaxone is indicated over maintaining broad-spectrum empiric coverage.

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1
Identify the patient's primary clinical syndrome.
The patient is in septic shock secondary to an infected, obstructing right ureteral calculus.
Hypotension, tachycardia, fever, leukocytosis, and CT evidence of a proximal ureteral stone with hydronephrosis confirm the diagnosis.
2
Determine the necessary surgical intervention.
Immediate decompression of the urinary tract is required via percutaneous nephrostomy or retrograde ureteral stenting.
An obstructed, infected kidney is a closed space infection (urologic emergency) that cannot be sterilized with antibiotics alone. Definitive stone removal (e.g., ureteroscopy) is contraindicated during acute sepsis due to the risk of worsening shock.
3
Select the appropriate pharmacologic therapy based on the provided data.
Transition to intravenous ceftriaxone.
The urine culture results provide specific sensitivities. Good antibiotic stewardship requires using a targeted agent (ceftriaxone) rather than unnecessarily continuing broad-spectrum empiric antibiotics.

Anahtar Kavram

An infected, obstructing ureteral calculus requires emergent urinary tract decompression (via percutaneous nephrostomy or ureteral stent) combined with culture-directed targeted antibiotics.
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