Management of Bilateral Hydroureteronephrosis with UTI and Ureteral Calculi

Initial Management

In cases of sepsis and/or obstructed kidney with infection, urgent decompression of the collecting system is strongly recommended via either percutaneous nephrostomy (PCN) or ureteral stenting, as recommended by the European Association of Urology 1
The presence of bilateral hydroureteronephrosis with wall thickening concerning for UTI represents a urologic emergency that requires immediate intervention to prevent sepsis and potential kidney damage, according to the American Urological Association 2
Urine should be collected for culture and antibiogram testing before and after decompression, as suggested by the European Association of Urology 1
Antibiotics should be given immediately and the regimen should be re-evaluated following antibiogram findings, as recommended by the European Association of Urology 1
The presence of purulence at the time of instrumentation mandates placement of a ureteral stent or nephrostomy tube, aborting any stone removal procedure, and continuing broad-spectrum antibiotics pending cultures, as suggested by the American Urological Association 3

Retrograde ureteral stenting is usually appropriate for patients with flank pain, fever, and leukocytosis with a positive urinalysis for infection, according to the American College of Radiology 4
Cystoscopic retrograde ureteral decompression with double-J stents is an effective option for decompressing the collecting system in cases of sepsis, as recommended by the American College of Radiology 5
PCN is usually technically successful in the setting of pyonephrosis and often results in marked clinical improvement, as reported by the American College of Radiology 4
PCN can yield important bacteriological information and alter antibiotic treatment regimens by correctly identifying the offending pathogen, according to the American College of Radiology 4

For a 4 mm mid-ureteral calculus, both medical expulsive therapy (MET) and ureteroscopy are appropriate options once the infection has resolved, as recommended by the European Association of Urology 1
Medical expulsive therapy using α-blockers is efficacious for ureteral stones, with the greatest benefit for stones >5 mm in the distal ureter, according to the European Association of Urology 1
For stones ≤10 mm in the ureter, clinicians may offer SWL (shock wave lithotripsy) or URS (ureteroscopy) after the infection is controlled, as suggested by the American Urological Association 2

Stone material should be sent for analysis to guide future prevention strategies, as recommended by the American Urological Association 3
If recurrent urinary tract infections occur, continued long-term monitoring and low-dose antibiotic prophylaxis may be necessary, according to the American College of Radiology 4

Postprocedural bacteremia and sepsis are common when infected urinary tracts are drained, so preprocedural antibiotics are recommended when urosepsis is suspected or known to be present, as suggested by the American College of Radiology 4
Limiting guidewire and catheter manipulation during initial access for decompression of the infected collecting system can minimize the risk of urosepsis, according to the American College of Radiology 7
The presence of bilateral hydroureteronephrosis with wall thickening suggests a more severe condition that requires careful monitoring for systemic inflammatory response syndrome, as recommended by the American College of Radiology 7