From the Guidelines
The patient with a CT scan of the abdomen showing gas in the right renal collecting system with a ureteral stent in place, concerning for genitourinary (GU) perforation, should be managed with close monitoring and consideration for urgent intervention, such as imaging-guided drainage or surgical exploration, depending on the patient's hemodynamic stability and clinical presentation 1.
Initial Assessment
- The presence of gas in the renal collecting system is concerning for a genitourinary perforation, which requires prompt evaluation and management.
- The ureteral stent in place may be an attempt to manage a known or suspected ureteral injury, but the presence of gas in the collecting system suggests a possible complication or failure of the stent.
Management Options
- Non-operative management (NOM) may be considered in hemodynamically stable patients with minor to moderate injuries, but the presence of gas in the collecting system may indicate a more severe injury requiring operative intervention 1.
- Imaging-guided drainage may be an option for managing a suspected urinoma or abscess, but the presence of a ureteral stent and gas in the collecting system may require a more invasive approach.
- Surgical exploration may be necessary in cases of hemodynamic instability, severe injury, or failed non-operative management, and should be considered in consultation with a urologist or trauma surgeon.
Ureteral Injury Management
- Ureteral stenting is recommended for partial ureteral injuries, but may not be sufficient in cases of complete transection or avulsion 1.
- Percutaneous nephrostomy may be necessary in cases of failed ureteral stenting or complete ureteral transection, with delayed surgical repair planned as needed.
- Surgical repair is indicated in cases of complete ureteral transection, with options including primary uretero-ureterostomy or ureteral re-implant with bladder psoas hitch or Boari flap 1.
From the Research
Next Steps for Patient with CT Scan Showing Gas in the Right Renal Collecting System
- The patient's condition, with a ureteral stent in place and gas in the right renal collecting system concerning for genitourinary (GU) perforation, requires careful management to prevent further complications 2, 3.
- The presence of a ureteral stent and gas in the renal collecting system may indicate a perforation or rupture of the urinary collecting system, which can lead to serious consequences such as urinoma, abscess formation, urosepsis, infection, and subsequent irreversible renal impairment 3.
- Management options for patients with GU perforation or rupture may include:
- Double-J stent placement to relieve obstruction and promote healing 3, 4.
- Conservative management with antibiotics and monitoring for symptoms or signs of urinary extravasation 5.
- Interventional procedures such as percutaneous drain placement or surgical repair in cases of severe or symptomatic perforation 5.
- It is essential to confirm the correct deployment of the stent via X-ray after insertion to prevent complications such as renal perforation 2.
- Regular follow-up imaging, such as CT scans, may be necessary to monitor the patient's condition and assess the resolution of the perforation or rupture 5, 6.