A 60-year-old woman with ureteric obstruction from advanced cervical carcinoma develops fever of 39 degrees Celsius, rigors and hypotension. Ultrasound shows gross hydronephrosis with echogenic debris within the pelvicalyceal system. After initial resuscitation and intravenous antibiotics, the most appropriate step to achieve source control is:

• A Continuation of intravenous antibiotics without drainage
• B Antegrade ureteric stent insertion under general anaesthesia
• C Urgent ultrasound-guided percutaneous nephrostomy under local anaesthesia ✓
• D Percutaneous aspiration of the collecting system without catheter placement

Explanation

Pyonephrosis with septic shock requires immediate decompression of the obstructed collecting system, since antibiotics alone cannot sterilize pus under pressure. Percutaneous nephrostomy is preferred in the septic patient because it is quick, needs only local anaesthesia and sedation, and avoids manipulation of the oedematous inflamed ureteric urothelium that can precipitate further bacteraemia. Simple aspiration without leaving a catheter does not provide continued drainage and recurrence of sepsis is expected.

Reference: Grainger and Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.