Case Study - July 2011

A 56 year old gentleman presented 3 weeks after having had a low anterior resection, partial cystectomy and loop ileostomy for diverticular disease with abdominal pain. His bloods were normal, with a creatinine of 123 and normal inflammatory markers. He underwent a CT scan.

  1. What do the CT images show?
  2. How could you manage this acutely?
  3. What could you do next?

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. The top image shows right sided hydronephrosis. The second image shows a collection in the pelvis around the rectum which is pushing the bladder anteriorly. The bottom image is a contrast study and it demonstrated a leak from the right ureter into this pelvic collection, as distal to this, the right ureter did not opacify.
  2. The option of choice would be a nephrostomy performed under local anaesthetic. Subsequent nephrostogram confirmed the ureteric injury in the distal right ureter. He should also have a urethral catheter placed, to lower the bladder pressure.
  3. Ureteric stents could be placed antegrade if possible to bridge the defect and allow it to heal. Other options include early reimplantation. If successful, the patient should undergo removal of nephrostomy, followed by urethral trial without catheter. This patient underwent a ureteric stent followed by a ureteroscopy, which revealed a stricture in the injured ureter. He is planned for a reimplantation.

illustrative image for answer to question $n

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