A 52-year-old woman undergoes a sigmoid resection with primary anastomosis for recurrent diveiculitis. She returns to the emergency room 10 days later with left flank pain and decreased urine output; laboratory examination is significant for a white blood cell (WBC) count of 20,000/mm3 . She undergoes a CT scan that demonstrates new left hydronephrosis, but no evidence of an intraabdominal abscess. Which of the following is the most appropriate next step in management?
The patient should undergo an intravenous pyelogram for a suspected ureteral injury. After gynecologic surgeries, colorectal surgery is the most common cause of iatrogenic ureteral injuries. Intraoperatively, intravenous administration of methylene blue or indigocyanine green may facilitate identification of an injury. However, delay in diagnosis is common, and patients may present with flank pain, fevers, and signs of sepsis, ileus, or decreased urine output. CT scan may demonstrate hydronephrosis or a fluid collection (urinoma). Initial diagnosis and management should include urinalysis, although hematuria may not always be present; percutaneous nephrostomy tube or retrograde ureteral catheterization; percutaneous drainage of fluid collections; and identification of the location of ureteral injury. Surgical management should be delayed if diagnosis is late (10-14 days), and operative strategy is dependent on the location of the injury. Diagnostic imaging such as a pyelogram or nuclear medicine scan may be helpful to identify the site of the injury.
Intravenous pyelogram
Intravenous antibiotics and repeat CT in 1 week
Administration of intravenous methylene blue
No fuher management if urinalysis is negative for hematuria
Preoperative assessment and monitoring in anaesthesia