What is the best treatment approach for a woman with bilateral hydronephrosis, uterine prolapse, stress urinary incontinence, impaired renal function, and a significant post-void residual?

Management of Bilateral Hydronephrosis with Uterine Prolapse, Stress Incontinence, Elevated Creatinine, and PVR

Surgical intervention with prolapse correction is the definitive treatment for this patient with bilateral hydronephrosis, uterine prolapse, stress incontinence, elevated creatinine, and PVR of 100cc to prevent further renal deterioration. 1, 2, 3

Initial Assessment and Risk Stratification

• This patient should be classified as "unknown risk" requiring complete evaluation due to the presence of bilateral hydronephrosis with elevated creatinine, indicating potential upper urinary tract damage 4
• Multichannel urodynamics are indicated to assess both storage and emptying function, particularly with the combination of stress incontinence and elevated PVR 4
• Upper tract imaging (CT urography or MRU) is essential to evaluate the severity of hydronephrosis and rule out other causes of obstruction 4
• Renal function assessment is critical given the elevated creatinine, as bilateral hydronephrosis from pelvic organ prolapse can progress to end-stage renal disease if not addressed promptly 2, 3

Preoperative Considerations

• Stress testing with prolapse reduction should be performed to assess for occult stress incontinence that may be unmasked after prolapse correction 4
• Post-void residual measurements should be monitored regularly, as the current PVR of 100cc may indicate developing voiding dysfunction 4
• The combination of stress incontinence with elevated PVR suggests possible detrusor underactivity coexisting with outlet dysfunction 4
• Patients with elevated preoperative PVR may be at increased risk for postoperative voiding difficulties following stress incontinence surgery 4

Surgical Management

• Correction of the uterine prolapse is the priority to relieve bilateral ureteral obstruction and prevent further renal deterioration 1, 5

• Surgical options should address both the prolapse and stress incontinence components 4

• For the prolapse component, options include:

  • Vaginal approach with apical suspension (vaginal hysterectomy with vault suspension) 5
  • Minimally invasive approaches such as laparoscopic or robotic sacrocolpopexy 6

• For the stress incontinence component, options include:

  • Mid-urethral synthetic sling (retropubic or transobturator) 4
  • Autologous fascia pubovaginal sling (may be preferred with voiding dysfunction) 4
  • Burch colposuspension (particularly if undergoing concomitant abdominal surgery) 4

Specific Considerations for This Case

• The presence of elevated creatinine and bilateral hydronephrosis makes this an urgent case requiring prompt intervention 2, 3
• Temporary measures such as ureteral stenting or pessary insertion may be considered as a bridge to definitive surgery 2, 6
• Native tissue repair may be preferred over mesh-based repairs if there are any contraindications to mesh 5
• The elevated PVR warrants careful consideration of anti-incontinence procedures that may further increase outlet resistance 4

Postoperative Management

• Close monitoring of renal function with serial creatinine measurements 2, 3
• Follow-up imaging to confirm resolution of hydronephrosis 5, 6
• PVR measurements to ensure adequate bladder emptying 4
• Voiding diary to track urinary symptoms and continence status 4

Potential Complications and Pitfalls

• Failure to address the prolapse promptly can lead to irreversible renal damage and end-stage renal disease 2, 3
• Treating only the stress incontinence without addressing the prolapse would be inappropriate and potentially harmful 1, 5
• Performing anti-incontinence surgery without addressing voiding dysfunction could worsen retention 4
• Patients should be counseled about the potential need for intermittent catheterization if voiding dysfunction persists postoperatively 4