DISCHARGE DIAGNOSIS:
Proximal right ureteral
stricture with retrocaval ureter.
PROCEDURES: Robotic-assisted right ureterolysis.
BRIEF HISTORY: This is an 80-year-old female with a history
of dementia, hypothyroidism, and spinal stenosis who was initially admitted to
the West Boca Medical
Center in 08/2008 after a
fall. She had continued pain along the
left side along with gross hematuria which prompted a CAT scan of her abdomen
and pelvis. The CAT scan of her abdomen
and pelvis revealed a calculus in the right ureter with severe proximal right
hydronephrosis, perinephric stranding, and periureteral inflammation. She was observed overnight; however, pain did
not subside, and she was taken to the operating room on 08/31/08. A right ureteroscopy was performed which
revealed a markedly tortuous right ureter with medial deviation, and it was
unable to be stented from below. She
required a percutaneous nephrostomy tube for renal drainage on the right side
that day. Additionally, multiple times
by interventional radiology was unsuccessful at bypassing the stricture in an
antegrade fashion. She was subsequently
discharged and brought back to the hospital on 10/01/08 for a repeat attempt of
right ureteroscopy. We were unable to
bypass the stenosis, tortuosity, and stricture of her right ureter in a
retrograde fashion as well as an antegrade fashion down her nephrostomy tube
tract. The patient and family was
consented in all the risks, benefits, alternatives were explained and they
agreed to undergo a robotic-assisted laparoscopy right-sided
ureteroureterostomy and ureterolysis for this obliterative
stricture of her ureter.
PAST MEDICAL HISTORY:
Alzheimer’s dementia,
hypothyroidism, and spinal stenosis.
ALLERGIES: None.
MEDICINES: Naprosyn, temazepam, Actonel, gabapentin,
Namenda, Synthroid, Razadyne, and Aricept.
SOCIAL HISTORY: Denies alcohol or drug use. She currently lives with her daughter,
although has been under rehab facility more recently. Her daughter’s name is Alda Keene, and the
phone number for her is 561-483-4348.
FAMILY HISTORY: Denies history of renal disease,
ureterolithiasis, and nephrolithiasis.
HOSPITAL COURSE: On 10/29/08, the patient underwent a
robotic-assisted laparoscopic ureterolysis with replacement of her nephrostomy
tube.
SURGICAL FINDINGS:
A dilated ureter that course
proximally and medially. It appeared as
if the ureter was completely encompassed by a dense inflammatory area of
desmoplastic reaction with possible location in a retrocaval fashion. At this point, we felt we would be putting
the patient in excess harm to carry dissection behind the inferior vena cava
and decided to leave her with an indwelling nephrostomy tube. She tolerated the procedure well and there
were no operative complications. She
recovered uneventfully. At the time of
discharge, she had a creatinine of 0.5 and a hemoglobin and hematocrit of
10.1/29.8. There was no discharge
medication. She was sent back to her
rehab facility with an indwelling right nephrostomy tube. The patient’s family and I discussed that
should they want further workup, MR urogram could be performed to further
delineate the course of her ureter, and I did refer them for a second opinion
should they want further surgical intervention to address her ureter. I explained to them what our surgical
findings were and that there was indeed a possibility of her having a
retrocaval ureter which although may have not caused her issue for her
lifetime. A small stone may have lodged
itself in the ureter causing a stricture and perinephric inflammation. At this point, the family said they would
like to avoid other interventions or satisfy with leaving the nephrostomy tube
in place. The patient was given
instructions how to care for the nephrostomy tube and for the urine bag. She was discharged to rehab in stable
condition. They will follow up with me
as an outpatient to either arrange for serial nephrostomy tube changes or to
discuss further evaluation and workup should they desire.
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