Should we arrange urgent follow‑up for a 70‑year‑old male with prior right nephrectomy who presents with markedly enlarged prostate causing bladder outlet obstruction, bilateral hydronephrosis (left greater than right), retroperitoneal and para‑aortic lymphadenopathy concerning for prostate or rectal malignancy, acute renal failure and urinary tract infection, after missing his post‑ER clinic visit?

Urgent Follow-Up is Absolutely Critical and Must Be Arranged Immediately

This patient requires immediate, proactive outreach and urgent urologic follow-up—this is a medical emergency that was incompletely managed, with life-threatening complications still present and high risk of irreversible renal damage, sepsis, and death if left unaddressed.

Why This Patient Cannot Be Lost to Follow-Up

Immediate Life-Threatening Issues Present

• Bilateral hydronephrosis in a solitary kidney equivalent: This patient has only one functioning kidney (prior right nephrectomy) with severe left hydronephrosis, placing him at extremely high risk of rapid, irreversible renal failure 1
• Obstructed kidney with infection history: The combination of obstruction and recent UTI creates ongoing sepsis risk, which is considered a non-deferrable emergency requiring urgent intervention 1
• Acute renal failure: Already present and likely worsening without definitive management 2
• Suspected malignancy: Retroperitoneal and para-aortic lymphadenopathy concerning for prostatic or rectal cancer requires urgent tissue diagnosis and staging 3, 4

High Risk of Catastrophic Deterioration

• Median survival with malignant ureteral obstruction is less than 7 months, and this patient has bilateral obstruction with lymphadenopathy suggesting advanced disease 3
• Patients with indwelling catheters have increased risk of recurrent UTIs and antibiotic resistance, which can rapidly progress to life-threatening sepsis, particularly with resistant organisms 1
• Hydronephrosis is an independent prognostic factor for progression and time to death in prostate cancer, making urgent evaluation critical 4
• Clinical suspicions of obstruction may not correlate with imaging changes in patients with malignancy or retroperitoneal processes—his obstruction could worsen acutely without warning 2

Specific Actions Required Now

Immediate Contact and Scheduling

• Proactively contact the patient via phone, text message, or even home visit if necessary—do not wait for him to call 1
• Schedule urgent urology appointment within 1-2 weeks maximum, or sooner if possible 1
• Consider telemedicine initial contact if patient has barriers to in-person visit, but this must lead to definitive in-person evaluation 1
• Verify Foley catheter is functioning and arrange for catheter care/monitoring until definitive treatment 1

Urgent Diagnostic Workup Needed

• PSA level and prostate biopsy to establish diagnosis of suspected prostatic malignancy 4
• Repeat renal function tests (creatinine, eGFR) to assess current kidney function 2
• Urine culture to evaluate for ongoing or recurrent infection 1
• Consider cystoscopy to evaluate bladder and prostatic obstruction 3
• Possible CT-guided biopsy of lymphadenopathy if prostate biopsy non-diagnostic 3

Definitive Management Planning

• Bladder outlet obstruction requires intervention: Options include TURP, medical management, or suprapubic catheter depending on cancer status 1
• If malignancy confirmed, initiate androgen deprivation therapy which may relieve obstruction and improve hydronephrosis 4
• Persistent hydronephrosis may require ureteral stenting or nephrostomy even after hormonal treatment begins 3, 4
• Multidisciplinary tumor board discussion should occur once diagnosis established 1

Critical Pitfalls to Avoid

• Do not assume stable imaging means stable clinical status: Patients with retroperitoneal malignancy can have obstruction without corresponding dilation changes on ultrasound 2
• Do not delay intervention waiting for "elective" scheduling: This patient's presentation meets criteria for urgent/emergent care given solitary kidney with obstruction and infection 1
• Do not underestimate sepsis risk: Patients with indwelling catheters and history of UTI in setting of obstruction can rapidly decompensate to urosepsis 1, 5
• Do not miss the window for renal preservation: Prolonged obstruction in a solitary kidney can lead to irreversible renal failure requiring dialysis 1

Documentation and Communication

• Document all attempts to contact patient including dates, times, and methods used 1
• Consider certified letter if phone contact unsuccessful 1
• Coordinate with primary care physician to assist with patient outreach 1
• Alert emergency department that patient may present with acute decompensation and needs expedited urology consultation 1

The combination of solitary kidney function, bilateral obstruction, suspected malignancy, and recent infection makes this a urologic emergency that demands immediate, aggressive follow-up efforts. 1, 2, 3, 4