A 75-year-old male with a long history of nephrolithiasis has been suffering with recurrent urinary tract infections and debilitating dysuria. After obtaining urine from the left renal pelvis, which appeared clear, a retrograde pyelogram is performed. What is your next step?
A 75-year-old male with a long history of nephrolithiasis has been suffering with recurrent Pseudomonas aeruginosa urinary tract infections and debilitating dysuria. He has undergone two percutaneous nephrolithotomies (PCNL) in the past and is currently stone free based on his last computed tomography scan. His stones were not infection-related.
The patient had a cystoscopy performed recently that revealed an open channel after undergoing a TURP without any obvious abnormalities in the bladder. Decision is made to take the patient to the operating room to perform localizing cultures. After obtaining urine from the left renal pelvis, which appeared clear, a retrograde pyelogram (RPG) is performed (figure 1).
A. Advance ureteral catheter to upper pole
The upper pole calyx is not readily identified on the initial RPG, leading one to suspect an abnormality in this area. After advancing the ureteral catheter and injecting more contrast, the upper pole begins to fill incompletely with a narrow infundibulum (figure 2). The ureteral catheter was able to be navigated to this dilated upper pole calyx with return of frank pus. This calyx is liked obstructed from infundibular stenosis leading to his recurrent infections. Ureteroscopy with concurrent infected urine would not be ideal in this situation. A ureteral stent can be attempted to be placed in the infected upper pole after confirming the diagnosis.
Acquired infundibular stenosis is a rare yet potentially significant complication after PCNL. Stenosis usually develops within 1 year of initial PCNL and is associated with prolonged operative time, large stone burden, and extended postoperative nephrostomy tube drainage. Treatment for uninfected cases should be tailored to the degree of stenosis. Mild and moderate cases may be treated with observation and endoscopic dilation, respectively. In the case presented here, it is warranted to treat the infection prior to performing further endoscopic procedures.
Dr. Sorokin, endourology fellow at the University of Texas Southwestern Medical Center, Dallas, is section editor for Urology Times Clinical Quiz.
Infundibular stenosis after percutaneous nephrolithotomy. J Urol 2002; 167: 35-8.
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