What is the appropriate management for a patient with an obstructing ureteral stone, urinary tract infection, proteinuria, hypertension, and bradycardia?

Management of Obstructing Left Proximal Ureteral Stone with UTI and Hemodynamic Instability

This patient requires immediate urinary decompression via percutaneous nephrostomy or retrograde ureteral stenting combined with broad-spectrum antibiotics—antibiotics alone are insufficient and can lead to 40-60% mortality without drainage. 1, 2, 3

Immediate Priorities (Within Hours)

1. Urgent Urinary Drainage

• Percutaneous nephrostomy (PCN) is the preferred approach in this unstable patient with obstructed infected urine, achieving 92% survival versus 60% with medical therapy alone 1
• PCN demonstrates superior clinical cure rates (95.2%) compared to ureteral stenting (86.4%) at late follow-up, particularly when infection is present 3
• Retrograde ureteral stenting is an acceptable alternative if PCN is unavailable, though it may have lower success with severe obstruction 3
• The compromised antibiotic delivery into an obstructed kidney mandates drainage for infection resolution 3

2. Broad-Spectrum Antibiotic Therapy

• Initiate third-generation cephalosporin (ceftazidime) as first-line empirical therapy—this demonstrates superior clinical and microbiological cure rates compared to fluoroquinolones 1, 3
• Start antibiotics immediately before culture results, then adjust based on antibiogram findings at 48-72 hours 2, 3
• Continue antibiotics for 7-14 days after drainage: 7 days for patients with prompt clinical improvement, 10-14 days for delayed response or severe presentations 2

3. Address Hemodynamic Instability

• The bradycardia and hypertension require immediate evaluation—consider sepsis-induced cardiac dysfunction, medication effects, or underlying cardiac pathology
• Proteinuria may indicate acute kidney injury from obstruction or sepsis-related renal dysfunction
• Aggressive fluid resuscitation and hemodynamic monitoring are essential

Critical Procedural Considerations

If Purulent Urine is Encountered

• Abort any stone removal procedure immediately, establish drainage (stent or nephrostomy), continue broad-spectrum antibiotics, and obtain urine culture 1, 2
• The presence of purulence mandates aborting definitive stone treatment until infection clears 1

Antibiotic Prophylaxis for Drainage Procedure

• Administer preprocedural antibiotics within 60 minutes of nephrostomy or stent placement 1
• Base selection on prior urine culture results and local antibiogram patterns 1

Definitive Stone Management (Delayed Until Infection Resolves)

Timing

• Delay definitive stone treatment until sepsis completely resolves and the patient completes a full antibiotic course 2, 3
• Attempting stone removal during active infection significantly increases morbidity and mortality 2

Treatment Options for Proximal Ureteral Stone

• Ureteroscopy (URS) is first-line for most ureteral stones, with stone-free rates of 94-97% for distal stones and comparable success for proximal stones 3
• Shock wave lithotripsy (SWL) is an alternative with lower stone-free rates (85-90%) but less invasive 3
• Percutaneous nephrolithotomy (PCNL) may be considered for large proximal stones or if URS fails 1
• Open/laparoscopic/robotic surgery should not be offered as first-line therapy except in rare cases with anatomic abnormalities requiring reconstruction 1, 4

Procedural Safety Measures

• Use a safety guidewire for endoscopic procedures to facilitate rapid re-access if needed 1, 4
• Send stone material for analysis to guide metabolic evaluation and prevention strategies 1, 4

Follow-Up Requirements

Short-Term (1-2 Weeks)

• Urine culture 1-2 weeks after completing antibiotics to confirm eradication 3
• Repeat imaging 5-9 days post-definitive treatment to confirm stone-free status 3

Long-Term (1-6 Months)

• Monitor renal function at 1,3, and 6 months given the obstruction and infection 3
• Metabolic stone evaluation once acute episode resolves, including 24-hour urine collection 3
• Consider thiazide diuretics and/or potassium citrate for stone prevention based on metabolic workup 1

Common Pitfalls to Avoid

• Never treat obstructed infected urine with antibiotics alone—this is a life-threatening error that results in preventable mortality 1, 2, 3
• Do not attempt definitive stone removal during active infection, as this dramatically increases septic complications 1, 2
• If the nephrostomy tube has been in place ≥2 weeks at time of infection, consider replacing it before starting antibiotics to improve treatment response 2
• Ensure adequate drainage is confirmed before assuming antibiotic therapy will be effective 1