A 49-year-old woman is brought to the emergency department by her family due to severe rig… — USMLE Step 2 CK

A $49$ -year-old woman is brought to the emergency department by her family due to severe right-sided flank pain, shaking chills, and increasing confusion over the past $24$ hours. She has a history of recurrent urinary tract infections but does not take any daily medications. Her temperature is $39.5^\circ\text{C}$ ( $103.1^\circ\text{F}$ ), pulse is $128/\text{min}$ , respirations are $24/\text{min}$ , and blood pressure is $82/50\text{ mm Hg}$ . Physical examination reveals marked right costovertebral angle tenderness and delayed capillary refill.

Laboratory studies show the following:

Parameter	Value
Leukocyte count	$22,000/\text{mm}^3$ (with $16\%$ bands)
Serum creatinine	$2.4\text{ mg/dL}$
Blood urea nitrogen	$42\text{ mg/dL}$

Following initial intravenous fluid resuscitation and empirical broad-spectrum antibiotic administration, a non-contrast CT scan of the abdomen and pelvis is obtained. The imaging demonstrates a $14\text{-mm}$ calculus lodged in the proximal right ureter with severe ipsilateral hydroureteronephrosis and perinephric fat stranding. Which of the following is the most appropriate next step in management?

Placement of a percutaneous nephrostomy tubeCevap
B
Ureteroscopic stone extraction
C
Extracorporeal shock wave lithotripsy
D
Continued observation with intravenous antibiotic therapy
E
Insertion of a transurethral Foley catheter

Cevap

Placement of a percutaneous nephrostomy tube

The correct answer is placement of a percutaneous nephrostomy tube. This patient is presenting with obstructive pyelonephritis complicated by septic shock, as evidenced by her fever, flank pain, marked leukocytosis, altered mental status, and severe hypotension. An infected, obstructed collecting system is a life-threatening urologic emergency. Because antibiotics cannot effectively penetrate an obstructed, highly pressurized renal unit, medical therapy alone is insufficient. Immediate mechanical decompression is mandatory to establish source control and drain the purulent urine. This emergency decompression is achieved through either the placement of a percutaneous nephrostomy tube or a retrograde ureteral stent. Definitive stone management (e.g., laser lithotripsy) is deferred until the patient is hemodynamically stable and the acute infection has resolved.

Adım Adım Çözüm

Analyze the patient's clinical presentation.

The patient has fever, flank pain, leukocytosis, and profound hypotension (

82/50\text{ mm Hg}

Identifying systemic inflammatory response syndrome and end-organ hypoperfusion confirms the diagnosis of septic shock.

Interpret the imaging findings in the context of the clinical picture.

CT shows a large proximal ureteral stone causing hydronephrosis in a septic patient.

This confirms obstructive pyelonephritis, which is a closed-space infection representing a true urologic emergency.

Determine the necessary therapeutic intervention.

Immediate mechanical decompression of the infected collecting system is required.

Intravenous antibiotics alone are inadequate because they cannot reach effective concentrations within an obstructed, pressurized renal unit.

Select the appropriate surgical modality for decompression.

Percutaneous nephrostomy tube placement (or retrograde ureteral stenting) is chosen over definitive stone extraction.

Definitive stone removal (e.g., ureteroscopy, ESWL) is contraindicated during sepsis due to the risk of worsening bacteremia from pressurized irrigation.

Anahtar Kavram

Obstructive pyelonephritis complicated by sepsis is a urologic emergency that mandates immediate mechanical decompression of the collecting system via a percutaneous nephrostomy tube or retrograde ureteral stent, rather than definitive stone extraction.

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