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Abstract: The patient, a 64-year-old female, complained of left-sided lumbar soreness and swelling with weakness for more than 2 years, and her symptoms worsened after activity and exposure to cold, but she had not been treated systematically. After coming to our hospital for relevant examinations, the patient’s medical history and the results of urological ultrasonography and renal ureteral bladder enhancement CT reports suggested the presence of left hydronephrosis and stenosis of the left pelvic-ureteral junction. After the surgical treatment, the patient recovered.
Basic information】Female, 64 years old
Disease Type】Left hydronephrosis, moderate dilatation of the left renal pelvis, widening of the upper part of the left ureter, and stenosis of the left pelvic ureteral junction
Hospital】Shengjing Hospital of China Medical University
Date of consultation】April 2022
Treatment plan] Left laparoscopic pyeloplasty + double pigtail ureteral stent (DJ tube) placement + drug therapy (cefuroxime sodium for injection)
Treatment period】6 days of preoperative preparation, 7 days of postoperative discharge
Treatment effect】The patient’s left hydronephrosis and left pelvic ureteral junction stenosis obstruction was released
I. Initial consultation
The patient complained of left-sided lumbar soreness and swelling in the past 2 years, which could be relieved by rest and aggravated by activity and cold, with occasional urinary frequency and urgency, without urinary pain and hematuria, etc. After self-administered oral anti-inflammatory drug treatment (specific details unknown), the symptoms were slightly relieved. Recently, the patient had no significant wasting, normal stools, and poor sleep at night. No special medical history in the past. He did not have any bad habits such as smoking and alcohol. Ultrasound examination of the urinary tract was performed in our outpatient clinic, suggesting moderate dilatation of the left renal pelvis and calyces with widening of the upper left ureter. Based on the patient’s complaints, medical history and urological ultrasound findings, the patient was initially diagnosed with left hydronephrosis to be investigated and was admitted to the hospital.
After admission, the patient’s medical history and routine physical examination were performed. The patient was in fair general condition, with stable vital signs and slight percussion pain in the left renal area on physical examination, and no significant abnormality in the right renal area. There was no obvious pressure pain and percussion pain in the ureteral region bilaterally, and no obvious masses were palpated. The relevant examinations and laboratory tests were completed, which indicated that the blood routine, urine routine, five coagulation items, liver and kidney function and blood electrolytes were normal. The electrocardiogram and cardiac ultrasound were generally normal. ECT showed that the right kidney function was normal and the left kidney function was moderately reduced.
II. Treatment history
Since the patient met the indication for surgery and there was no clear contraindication to surgery, the patient decided to undergo surgery after a full explanation to the patient. After completing the preoperative examination, the patient underwent left-sided laparoscopic pyeloplasty + double pigtail ureteral stent (DJ tube) placement under general anesthesia, and drainage tubes were placed in the operated area, and the operation went smoothly, and the patient returned to the ward safely after the operation. The patient’s general condition was good after the operation, and his vital signs were stable. The patient was given antibiotics with cefuroxime sodium for injection to prevent infection for 5 days after the operation.
III. Treatment effect
Three days after the operation, the patient’s drainage tube in the operation area drained less than 20 ml in 24 hours, and the drainage tube in the operation area was removed, and the urinary catheter was removed 7 days later. The patient was discharged from the hospital with a review of the urological CT indicating that the obstruction of the left pelvic-ureteral junction was relieved, the left hydronephrosis was reduced compared with the previous one, and the double pigtail tubes were left in a good position. The patient was instructed to remove the double pigtail tubes under cystoscopy 3 months after surgery and to review the recovery condition regularly.
IV. Notes
We are glad that the patient gradually recovered to health after undergoing surgical treatment. After discharge, they should drink more water, take more rest and be properly active. If symptoms such as hematuria are found, they should pay attention to the duration of hematuria, the color of hematuria and whether there are accompanying symptoms. The patient was rechecked liver and kidney function, ion, blood routine, and urological CT 1 month after discharge to clarify the occurrence of any surgical complications. He returned to our hospital 3 months after the operation to have the left double pigtail tube removed under cystoscopy.
V. Personal insight
Ureteral obstruction can cause a variety of conditions, such as hydronephrosis as in this patient. In such patients, if they are young, the procedure that preserves the renal unit should be chosen to the greatest extent possible; the choice of pyeloplasty in middle-aged and elderly patients should be fully considered. The goal of the procedure is to preserve as much renal function as possible, and if the patient’s kidney is severely impaired, pyeloplasty will not be of maximum value. For patients who are physically intolerant to larger procedures, have severe infections, and have severely impaired renal function, interventional nephrostomy may be used to relieve the obstruction first, and then proceed to the next step after the infection is controlled or the patient is physically able to tolerate the procedure.