Staged Management of an Obstructing Ureteral Stone with Associated Infection
Case at a Glance
A 41-year-old male with a strong family history of nephrolithiasis was scheduled for ureteroscopic lithotripsy for a 5mm obstructing ureteral stone. The procedure was aborted upon intraoperative discovery of purulent urine proximal to the stone. Management was revised to a staged approach, beginning with ureteral stent placement to drain the infection, followed by a delayed definitive stone removal.
Patient's Story
The patient is a 41-year-old male with a significant family history of kidney stones affecting both paternal and maternal sides for over two generations. While he had previously passed a 3mm stone without intervention, he experienced persistent symptoms from a larger 5mm stone, leading him to seek urological consultation and subsequent surgical intervention.
Initial Assessment
The patient presented with symptoms of renal colic. His personal history was significant for a prior 3mm calculus, and his family history indicated a strong genetic predisposition to stone formation. Imaging studies confirmed an obstructing 5mm calculus in the ureter. Due to his inability to pass the stone spontaneously and the associated symptoms, a ureteroscopic laser lithotripsy was planned.
The Diagnostic Journey
The patient was taken to the operating room for the planned ureteroscopy. Upon advancing the ureteroscope to the location of the stone, the surgical team observed purulent fluid (pus) behind the obstruction. This finding indicated an active, significant infection (infected hydronephrosis) proximal to the stone. Performing lithotripsy in this setting poses a high risk of forcing bacteria from the pressurized, infected renal pelvis into the bloodstream, potentially leading to urosepsis, a severe systemic infection. Consequently, the clinical priority shifted from stone removal to source control and drainage of the infection.
Final Diagnosis
Obstructing 5mm Ureteral Calculus with Infected Hydronephrosis.
Treatment Plan
A staged management approach was adopted, which is the standard of care in this clinical scenario.
Initial Procedure: The planned lithotripsy was aborted. Instead, a ureteral stent was placed. The stent is a flexible tube that is positioned alongside the stone, creating a channel to bypass the obstruction and allow the infected urine to drain from the kidney into the bladder. This relieves pressure, alleviates pain, and allows for the effective treatment of the infection. The patient was started on a course of intravenous antibiotics, later transitioned to oral antibiotics pending culture results.
Definitive Procedure: After a course of antibiotics to resolve the infection (typically 1-4 weeks), the patient will return for a second, definitive procedure. This will involve a repeat ureteroscopy, laser lithotripsy to fragment and remove the stone, and removal of the stent.
Outcome and Follow-up
The patient tolerated the stent placement well and was discharged on a course of oral antibiotics. He was educated on the rationale for the staged procedure, specifically the critical need to treat the infection before manipulating the stone to prevent life-threatening complications. He is scheduled for a follow-up visit and the definitive stone removal surgery in the near future. The prognosis with this staged approach is excellent.