What is the appropriate management for a patient with bilateral hydroureteronephrosis concerning for urinary tract infection and 4 mm kidney stones in the left ureter?

Management of Bilateral Hydroureteronephrosis with UTI and Ureteral Calculi

For a patient with bilateral hydroureteronephrosis concerning for urinary tract infection and 4 mm left ureteral calculi, urgent decompression of the urinary system via retrograde ureteral stenting or percutaneous nephrostomy is required, followed by appropriate antibiotic therapy and subsequent definitive stone management once the infection is resolved.

Initial Management

Urgent Decompression

• In cases of sepsis and/or obstructed kidney with infection, urgent decompression of the collecting system is strongly recommended via either percutaneous nephrostomy (PCN) or ureteral stenting 1
• The presence of bilateral hydroureteronephrosis with wall thickening concerning for UTI represents a urologic emergency that requires immediate intervention to prevent sepsis and potential kidney damage 1
• When infection complicates pre-existing stone disease, the primary aim is to treat the infection and delay definitive stone management until the infection has cleared 2

Antibiotic Therapy

• Urine should be collected for culture and antibiogram testing before and after decompression 1
• Antibiotics should be given immediately and the regimen should be re-evaluated following antibiogram findings 1
• The presence of purulence at the time of instrumentation mandates placement of a ureteral stent or nephrostomy tube, aborting any stone removal procedure, and continuing broad-spectrum antibiotics pending cultures 1

Decompression Options

Retrograde Ureteral Stenting

• Retrograde ureteral stenting is usually appropriate for patients with flank pain, fever, and leukocytosis with a positive urinalysis for infection 1
• Cystoscopic retrograde ureteral decompression with double-J stents is an effective option for decompressing the collecting system in cases of sepsis 1
• Compared with PCN, retrograde ureteral stents may be associated with a higher risk of urosepsis in some patients with extrinsic ureteral obstruction 1

Percutaneous Nephrostomy (PCN)

• PCN is usually technically successful in the setting of pyonephrosis and often results in marked clinical improvement 1
• PCN can yield important bacteriological information and alter antibiotic treatment regimens by correctly identifying the offending pathogen 1
• In a retrospective analysis, patient survival was 92% when PCN was used, compared with 88% for open surgical decompression and 60% for medical therapy without decompression 1

Definitive Stone Management (After Infection Resolution)

Management of 4 mm Left Ureteral Calculi

• For a 4 mm mid-ureteral calculus, both medical expulsive therapy (MET) and ureteroscopy are appropriate options once the infection has resolved 1
• Medical expulsive therapy using α-blockers is efficacious for ureteral stones, with the greatest benefit for stones >5 mm in the distal ureter 1
• For stones ≤10 mm in the ureter, clinicians may offer SWL (shock wave lithotripsy) or URS (ureteroscopy) after the infection is controlled 1

Follow-up Imaging

• In patients with complex stones or anatomy, additional contrast imaging may be obtained if further definition of the collecting system and ureteral anatomy is needed 1
• Follow-up imaging is essential to ensure complete stone clearance, particularly when infection stones are suspected 3

Special Considerations

Infection Stones vs. Stones with Infection

• The relationship between urinary stones and UTIs shows two different clinical pictures: stones that develop following UTIs (infection stones) and metabolic stones complicated by UTIs (stones with infection) 3
• Complete stone removal is essential, especially for infection stones, to prevent recurrent UTIs and further stone growth 4
• Infected kidney stones refer to stones that form because of UTIs with urease-producing bacteria, secondarily infected stones, or stones obstructing the urinary tract leading to pyelonephritis 4

Prevention of Recurrence

• Stone material should be sent for analysis to guide future prevention strategies 1
• If recurrent urinary tract infections occur, continued long-term monitoring and low-dose antibiotic prophylaxis may be necessary 1
• Metaphylactic treatment is mandatory to prevent recurrences of infection stones 3

Potential Complications and Pitfalls

• Postprocedural bacteremia and sepsis are common when infected urinary tracts are drained, so preprocedural antibiotics are recommended when urosepsis is suspected or known to be present 1
• Limiting guidewire and catheter manipulation during initial access for decompression of the infected collecting system can minimize the risk of urosepsis 1
• The presence of bilateral hydroureteronephrosis with wall thickening suggests a more severe condition that requires careful monitoring for systemic inflammatory response syndrome 1