An obstructing stone with sepsis: decompress now, operate later
A 58-year-old woman presents to the emergency department with a 30-hour history of rigors, flank pain and vomiting. CT shows a 1.8 cm stone at the right ureteropelvic junction with moderate hydronephrosis; she has had no previous urological surgery. Temperature 39.2 °C, heart rate 122/min, blood pressure 92/58 mmHg after 1 L crystalloid, respiratory rate 24, oxygen saturation 96%. White cell count 19.6 ×10⁹/L, C-reactive protein 240 mg/L, lactate 2.6 mmol/L, creatinine 186 µmol/L (baseline 78), platelets 96 ×10⁹/L. Urinalysis shows nitrite-positive leucocytes; blood and urine cultures have been sent. She has been started on intravenous ceftriaxone and fluids by the medical team, who have asked your opinion about 'taking her to theatre tonight for laser'. The hospital has no interventional radiology on site overnight, and the operating theatre list is full until morning.
1. What is your immediate plan, and why is ureteroscopy with laser tonight the wrong operation?
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This is obstructed pyelonephritis with sepsis: fever, rigors, tachycardia, hypotension after fluid, raised lactate and thrombocytopenia in the presence of an obstructing stone. The source is the obstructed, infected upper tract, and drainage is the treatment that saves life.
Immediate steps: senior review, high-dependency or intensive care assessment, blood and urine cultures, broad-spectrum intravenous antibiotics covering Gram-negative organisms according to local resistance (for example piperacillin-tazobactam, or a third-generation cephalosporin plus gentamicin), careful fluid resuscitation guided by lactate and urine output, analgesia and antiemetics, and correction of any coagulopathy. Catheterise to monitor output. The key intervention is urgent decompression of the collecting system.
Ureteroscopy with laser is wrong tonight for three reasons: it is a definitive stone procedure that can wait, it risks pushing bacteria and fragments into the circulation and worsening sepsis, and instrumentation of an infected, inflamed ureter has a higher risk of perforation and bleeding. The theatre list being full is not a reason to delay drainage, which can be achieved by a retrograde stent or a nephrostomy, both of which are urgent procedures.
She needs decompression within hours, not a full stone operation.
2. How do you choose between a ureteric stent and a percutaneous nephrostomy in this hospital?
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Both effectively relieve obstruction, and randomised evidence shows broadly similar outcomes for sepsis control; the choice depends on anatomy, the operator, and the urgency.
Here, the stone is at the ureteropelvic junction and is 1.8 cm, which may make retrograde passage of a guidewire and stent difficult. A nephrostomy is often easier and more reliable in that situation, drains pus directly and allows urine sampling, and does not require general anaesthesia. However, there is no interventional radiology overnight. Options include: calling in the on-call interventional radiologist, transferring to a centre with IR, or having the urologist place an ultrasound-guided nephrostomy if trained and supported. A retrograde stent under local anaesthesia with sedation is another option and is appropriate if the ureter can be accessed; it avoids an external tube and may be preferable if the patient is unstable and transfer is hazardous.
Points that influence the decision: grossly purulent urine, a very dilated system, coagulopathy, and the ability to access the ureter. If retrograde stenting fails, percutaneous drainage must follow immediately rather than repeating attempts. Document the discussion and the chosen route, and ensure antibiotics are not delayed by the procedure.
3. Assume she is afebrile with normal lactate 72 hours later. What is the definitive treatment and when?
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The definitive treatment is stone clearance, but it should be delayed until sepsis has resolved and the patient is stable, typically after 1–2 weeks, with a negative urine culture and recovered renal function. Treating a 1.8 cm stone at the ureteropelvic junction is a planned procedure, not an emergency.
The options are ureteroscopy with laser lithotripsy, percutaneous nephrolithotomy, or shockwave lithotripsy. For a stone of this size, ureteroscopy may require staged treatment or a planned two-session approach, and a stent is often left in place. PCNL is a reasonable single-stage option depending on anatomy and local expertise, and may be preferred if the stone is hard and bulky. ESWL is less attractive for a 1.8 cm stone and may require multiple sessions.
If a nephrostomy was placed, it must not be removed until the tract is secure and the obstruction is definitively treated; if a stent was placed, it should be exchanged or removed at the definitive operation. Metabolic evaluation should follow, because stone disease is recurrent. She should be counselled about the risks of the chosen procedure and about prevention with fluid intake and dietary measures while awaiting surgery.