Uretero-Pelvic Junction Obstruction
Patient Presentation:
N.R., a 47 year old male presents to the ER complaining of left sided abdominal pain X 5 days, colic-like in nature, with bouts of pain increasing in intensity until this afternoon when the pain returned. Pt. states pain a 9/10 on pain scale, with episodes of vomiting for past two hours. N.R. reports having run a 10 km race this a.m. without difficulty. He is in training for a triathlon and exercises regularly. N.R. initially felt the pain may have been due to a muscle problem as it started after a rigorous workout in the gym 5 days prior and seemed to be exacerbated by movement. Pt. has maintained normal activity levels for past 5 days. Denies any change in appetite, urinary or bowel patterns, denies N/V/D until today. No significant medical history/ no previous surgeries. Denies taking any medications. Does not smoke; drinks 3-4 drinks/week.
Vital signs: BP 142/86, HR 102 sinus tachycardia, RR 24, T 38°C, SpO2 98% RA
Respiratory: Lungs clear to auscultation.
Abdomen: Bowel sounds heard in all quadrants, no guarding or rebound tenderness. Left sided CVA tenderness noted.
Labs: CBC and BMP results within normal range except for significant elevation in creatinine and BUN levels. Urinalysis normal.
CT scan: CT scan of abdomen shows left sided hydronephrosis and narrowing at pelvic-ureteral junction.
Lasix MAG3 Renogram: This is a contrast scan with bolus of Lasix® given to show renal clearance and pattern, and compares right and left sided renal function. Results shows left renal obstruction with 36% left renal function, with no involvement of right kidney.
Diagnosis:
Left renal uretero-pelvic junction obstruction
Treatment:
Pt. given IV Dilaudid® for pain relief, with NS for fluid replacement. Emergency surgery was done for temporary placement of a DJ stent (double J stent with both ends of stent coiled to ensure it remains in situ). Fibrous band is found around uretero-pelvic junction which is thought to have contracted due to inadequate hydration during 10 km race and is presumed to have had history of slowly tightening during times of renal stress. Urological surgeon explains this is not an uncommon occurrence in athletes who have congenital fibrous banding present in ureters. Stent is left in for a period of six weeks to allow for considerable inflammation around site of junction to subside allowing for future surgical repair, and to decrease chance of permanent renal damage. Retrograde endopyelotomy is then scheduled and completed, with release of fibrous band and scaffolding inserted to increase lumen of junction. Stent is left in situ for a further eight weeks to allow for renal tissue to fill in and absorb scaffolding into structure of uretero-pelvic junction. Stent is then removed.
Outcome:
Full recovery of left-sided renal function is expected and achieved which is ascertained by every 6 month Lasix MAG3 renograms showing steadily increasing renal output till 98% function achieved. Discussion is had with N.R. about the importance of maintaining good hydration particularly during exercise sessions.