Obstructing Ureteral Stone with Infection (Infected Hydronephrosis)

Algorithm Steps

1. ▶

   Start

   Obstructing Stone + Signs of Infection

   Ureteral stone with fever, pyuria, or sepsis

   1. ●

      Action

      Confirm Diagnosis

      Imaging + labs to confirm infected obstruction

      • CT without contrast: Stone location, hydronephrosis
      • UA: Pyuria, bacteriuria
      • Blood cultures BEFORE antibiotics
      • Urine culture if possible
      • Labs: CBC, BMP, lactate, procalcitonin
      1. ⚠

         Warning

         ⚠️ UROLOGICAL EMERGENCY

         Infected obstructed kidney = mortality risk

         • Obstructed + infected kidney is life-threatening
         • Can rapidly progress to septic shock
         • Antibiotics alone will NOT resolve
         • MUST decompress urgently
         1. ●

            Action

            Sepsis Resuscitation

            Follow SSC sepsis bundle

            • IV fluid resuscitation (30mL/kg crystalloid)
            • Lactate measurement
            • Blood cultures before antibiotics
            • Vasopressors if hypotensive despite fluids
            • ICU admission if septic shock
            1. ◆

               Decision

               Patient Hemodynamically Stable?

               Determines approach to decompression

               1. ●

                  Action

                  Stable: Stent or PCN

                  Either approach acceptable

                  • Ureteral stent: Can be done cystoscopically
                  • PCN: Percutaneous nephrostomy
                  • No clear superiority of one over other
                  • Choice based on availability and patient factors
                  • Stent may be preferred if stone likely passable
                  1. ●

                     Action

                     Ureteral Stent Placement

                     Retrograde approach via cystoscopy

                     • Cystoscopy + retrograde pyelogram
                     • Guidewire past obstruction
                     • Place double-J stent
                     • Confirm position with fluoroscopy
                     • May not be possible if stone impacted
                     1. ●

                        Action

                        Post-Decompression Care

                        Continue treatment, monitor response

                        • Continue IV antibiotics
                        • Monitor fever, WBC, clinical status
                        • Expect improvement within 24-48h
                        • If no improvement, consider abscess/alternative source
                        • May need repeat imaging
                        1. ⚠

                           Warning

                           ⚠️ Delay Definitive Stone Treatment

                           Do NOT attempt stone removal during active infection

                           • Wait until infection cleared
                           • Complete antibiotic course
                           • Afebrile for 48-72 hours minimum
                           • Definitive treatment 2-4 weeks later
                           • Immediate URS may worsen sepsis
                           1. ✓

                              Outcome

                              Definitive Stone Management

                              After infection resolved

                              • Ureteroscopy + laser lithotripsy
                              • PCNL for large/complex stones
                              • ESWL for selected cases
                              • Remove stent/nephrostomy after stone cleared
                        2. ⚠

                           Warning

                           ⚠️ Bilateral Obstruction/Solitary Kidney

                           Highest urgency - anuria/renal failure

                           • May present with anuria
                           • Acute kidney injury
                           • Decompress BOTH sides urgently
                           • Dialysis may be needed
                           • Nephrology consultation
                  2. ●

                     Action

                     Percutaneous Nephrostomy (PCN)

                     Antegrade drainage via renal puncture

                     • Ultrasound or fluoroscopic guidance
                     • Local anesthesia + sedation
                     • Puncture dilated collecting system
                     • Place 8-10 Fr nephrostomy tube
                     • Send urine for culture
               2. ●

                  Action

                  Unstable: PCN Preferred

                  Percutaneous nephrostomy faster/safer

                  • PCN can be done at bedside/IR
                  • Avoids OR/anesthesia in unstable patient
                  • Lower risk procedure in septic patient
                  • Ultrasound-guided placement
                  • Allows drainage + access for later
         2. ●

            Action

            Empiric IV Antibiotics

            Broad-spectrum within 1 hour

            • Cover gram-negative organisms primarily
            • Options: Pip-tazo, carbapenem, ceftriaxone + aminoglycoside
            • Adjust based on local resistance patterns
            • Adjust based on culture results
            • Continue until afebrile + cultures negative