A 10-year old girl undergoes an appendectomy that was converted from a laparoscopic to an open procedure due to significant periappendiceal inflammation. She was treated with antibiotics for five days and discharged. Two weeks later she returns with fever and right flank pain. A computerized tomography (CT) scan reveals right hydronephrosis and a dilated proximal ureter. Delayed images show no contrast in the ureter beyond the pelvic brim. There is a moderate fluid collection with some surrounding inflammation near the pelvic brim. Aspiration of the collection reveals urine. She is started on intravenous fluids and broad spectrum antibiotics. The next best step in management of this postoperative appendectomy patient with a urinoma is

 

A placement of a percutaneous right nephrostomy tube.

 

B expectant care as the ureteral obstruction will resolve as the inflammation resolves.

 

C CT guided drainage of the fluid collection.

 

D exploration to determine the cause of ureteral obstruction.

 

E ureterostomy.

A

correct answer

A placement of a percutaneous right nephrostomy tube.

 

This scenario describes the sequela of an injury to the right ureter during the appendectomy. With a delayed presentation of the injury such as this, the first priority is decompression of the urinary system to protect kidney function making expectant management inappropriate in this setting. In the scenario described, nephrostomy placement is the surest method to drain the urinary tract. Alternatively, cystoscopy with retrograde cystogram and stent placement may provide appropriate drainage if the anatomy is favorable. Operative exploration in the setting of the significant inflammation may be challenging and may not be needed. Further evaluation of the urinary tract anatomy can then be accomplished with subsequent plans made for urinary tract reconstruction when the inflammation has settled.

 

Ureteral injuries are very rare in children so the principles of management are extrapolated from those described for adults for the most part. Iatrogenic injuries that are recognized at the time that they happen can often be primarily repaired with a stent. Injuries that are delayed in presentation and most traumatic injuries will be better managed with drainage of the urinary tract. This is often accomplished with a nephrostomy tube. However, stent placement may also be a possibility depending on the anatomy presented. Formal repair can then be accomplished later by a number of methods.