I attended dozens of morbidity and mortality conferences as a resident. I heard cases that ranged from the seemingly impossible to the mundane, but for some reason, it was always just a conference. That changed after residency. As I wrote in a blog last year, I had an OR case that didn't go as planned. I'll admit that while that case certainly deviated from the way I had planned, I don’t know if I ever truly considered it a complication. The patient in that case did fine, so while I certainly thought a lot about the case, in the long run, it didn’t bother me that much.
A couple more recent cases are less clear. While both were difficult to stomach, they taught me valuable lessons. For the lawyers out there, I changed a few random details of these stories to ensure this blog is HIPAA compliant.
Case 1: Persistent flank pain
The first case involved a young man with no prior abdominal surgeries and a long history of intermittent right flank pain. The pain was associated with drinking large volumes of fluid. Prior to seeing me, his primary care doctor had obtained an ultrasound that showed a moderately enlarged right renal pelvis with no ureteral enlargement and a CT with contrast showing a clear crossing vessel. The parenchyma was preserved and the patient was absolutely confident that his pain only correlated with drinking large volumes of fluid. Based on his story and the imaging that I had, I diagnosed him with a right UPJ obstruction secondary to a crossing vessel and took him to the OR for a right robotic pyeloplasty. I did not do a renal scan before surgery.
In the OR, the case went fine. The ureter was easy to locate, the crossing vessel was obvious, and after isolating the ureter and transecting it, no urine leaked out until I further opened the ureter. I always find it somehow reassuring when during a pyelopasty that if the ureter is cut at the location where I think the obstruction is and no urine leaks out despite a nice full pelvis, it’s a sign I am doing the right thing. I proceeded to remove a segment of ureter and did a nice spatulation before suturing things back together. I placed a stent across the anastomosis. (Of note, the original paper by Anderson and Hynes describes a stentless anastomosis, but that itself is controversial [Br J Urol 1949; 21:209-14].)
A drain was left and removed after 2 days with minimal output and a normal Jackson-Pratt creatinine. The patient felt great and went home. He had some flank pain for the next 6 weeks, which I thought was related to the stent so I wasn't entirely sure if his original pain was gone, but a renal ultrasound before the stent came out showed no enlargement of the renal pelvis. I removed the stent and his pain was back. I repeated the renal US and it showed no significant enlargement of the renal pelvis. I finally ordered a renal scan that showed that the side of the operation had a minimally increased t 1/2 compared to the other side but nothing at all obstructive. (t 1/2 6 vs. 8 min). Given the patient’s pain, I even went so far as to perform ureteroscopy to look for an anatomic cause of his obstruction and saw nothing but a completely wide-open UPJ.
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