From the Guidelines
The most appropriate next step in management is to place bilateral ureteral stents to relieve the obstruction and improve renal function, as the patient has persistent hydronephrosis and impaired renal function due to ureteral obstruction, as evidenced by the high serum creatinine level and moderate-severe hydronephrosis on kidney ultrasound 1.
The patient's presentation with urinary hesitancy, dribbling, and a diffusely enlarged prostate suggests a possible obstructive cause, such as benign prostatic hyperplasia (BPH), which can lead to ureteral obstruction and subsequent hydronephrosis. The laboratory results, including a high blood urea nitrogen (BUN) level and serum creatinine level, indicate impaired renal function, which is consistent with ureteral obstruction.
The kidney ultrasound showing moderate-severe hydronephrosis and thinning of the renal cortex further supports the diagnosis of ureteral obstruction. Given the patient's age and frailty, it is essential to prioritize interventions that can quickly relieve the obstruction and improve renal function.
Placing bilateral ureteral stents is a minimally invasive procedure that can effectively relieve the obstruction and improve renal function, as evidenced by the decrease in serum creatinine level after stent placement 1.
While discussing goals of care (option A) is essential in patients with advanced age and frailty, it is not the most appropriate next step in management, as it does not address the underlying cause of the patient's symptoms and impaired renal function. Initiating intravenous 0.9% saline (option B) may help to improve hydration, but it does not address the underlying obstruction. Obtaining a noncontrast CT of the abdomen and pelvis (option C) may provide additional information about the underlying cause of the obstruction, but it is not the most appropriate next step in management, as it does not relieve the obstruction.
Therefore, placing bilateral ureteral stents (option D) is the most appropriate next step in management, as it can quickly relieve the obstruction and improve renal function, and is supported by the evidence from the American College of Radiology Appropriateness Criteria 1.
From the Research
Next Steps in Management
The patient presents with persistent hydronephrosis and impaired renal function due to ureteral obstruction. Considering the patient's condition, the most appropriate next step in management would be to address the underlying cause of the obstruction.
- Ureteral Obstruction: The patient's symptoms and laboratory results indicate a ureteral obstruction, which is causing hydronephrosis and impaired renal function 2.
- Treatment Options: The treatment options for ureteral obstruction include ureteral stent placement or percutaneous nephrostomy 3.
- Ureteral Stent Placement: Ureteral stent placement is a common treatment option for ureteral obstruction, but it can be associated with complications such as stent fragmentation, migration, and obstruction 4, 5.
- Percutaneous Nephrostomy: Percutaneous nephrostomy is another treatment option for ureteral obstruction, which can be used in cases where ureteral stent placement is not possible or has failed 3.
Most Appropriate Next Step
Considering the patient's condition and the treatment options available, the most appropriate next step in management would be to:
- Place bilateral ureteral stents to relieve the obstruction and improve renal function 3. This option is supported by the study by 3, which found that ureteral stent placement is an effective treatment option for hydronephrosis secondary to cervical cancer. However, it is essential to carefully evaluate the patient's condition and consider the potential complications associated with ureteral stent placement 4, 5.
The correct answer is: D Place bilateral ureteral stents.