Examkin

Soru

Zorluk: ZorPreoperative and Postoperative Care

A 61-year-old man is evaluated in the surgical ward for new-onset right-sided back pain. He is currently on postoperative day 77 following an open radical retropubic prostatectomy for localized prostate adenocarcinoma. His early postoperative recovery was routine, and he is tolerating a regular diet. Over the past 1212 hours, he has developed a fever and constant, dull pain in his right flank. He has a suprapubic catheter in place that is draining clear yellow urine. His temperature is 38.8∘C38.8^\circ\text{C} (101.8∘F101.8^\circ\text{F}), blood pressure is 130/82130/82 mmHg, pulse is 105105/min, and respiratory rate is 1616/min. Physical examination demonstrates a soft, non-tender abdomen and a clean lower midline incision. There is pronounced right-sided costovertebral angle tenderness. Laboratory evaluation reveals a leukocyte count of 14,800/mm314,800/\text{mm}^3. Analysis of the urine from the suprapubic catheter is negative for leukocyte esterase and nitrites, and shows 11-22 leukocytes/hpf. Which of the following is the most appropriate next step in management?

  1. CT scan of the abdomen and pelvis with intravenous contrastCevap
  2. B
    Empiric intravenous administration of ceftriaxone
  3. C
    Duplex ultrasonography of the lower extremities
  4. D
    Chest radiography
  5. E
    Irrigation of the suprapubic catheter

Cevap

CT scan of the abdomen and pelvis with intravenous contrast
The correct response targets the need for definitive imaging of the genitourinary tract. The distal ureters are anatomically close to the prostate and bladder neck, making them highly susceptible to iatrogenic injury (such as ligation, kinking, or transection) during a radical prostatectomy. A unilateral ureteral ligation typically remains clinically silent for several days until the proximal hydronephrosis becomes severe enough to cause flank pain, capsular distension, and subsequent fever. The critical diagnostic clue in this vignette is the combination of costovertebral angle tenderness with a pristine urinalysis. Because the injured ureter is completely blocked, no inflammatory cells or bacteria from the affected side can reach the bladder. Therefore, treating empirically for pyelonephritis is incorrect. A CT scan of the abdomen and pelvis with intravenous contrast is the gold standard for diagnosis, as it can demonstrate unilateral hydroureteronephrosis, delayed nephrograms, or contrast extravasation if a leak is present.

Adım Adım Çözüm

1
Analyze the timeline and localizing symptoms.
The patient has a fever and unilateral flank pain (CVA tenderness) on postoperative day 7 following a radical prostatectomy.
Identifying the 'W' (in this case, timeline points toward a deeper surgical complication or DVT, while the localizing sign points directly to the upper urinary tract).
2
Evaluate the laboratory findings in the context of the symptoms.
The urinalysis is completely normal despite symptoms suggestive of pyelonephritis.
A normal urinalysis in the presence of CVA tenderness and fever strongly suggests that the affected kidney is physically obstructed (e.g., ligated ureter), preventing abnormal urine/pus from reaching the bladder where the sample was collected.
3
Determine the highest-yield diagnostic test for the suspected surgical complication.
CT scan of the abdomen and pelvis with intravenous contrast is selected.
IV contrast is required to assess renal perfusion and, via delayed excretory phases, visualize the ureters to confirm mechanical obstruction (hydronephrosis) or extravasation of urine from an intraoperative ureteral injury.

Anahtar Kavram

Diagnosis and management of postoperative ureteral injury
Bu soruyu puanla

Konular

Preoperative and Postoperative Care

Bu konudan daha fazla soru