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A 32-year-old white female presented
with right flank pain which started about one year ago. The pain was
initially intermittent but had become almost constant. She previously
had a endopyelotomy two years ago for right UPJ obstruction. The
symptoms were temporarily relieved but had returned as described
above. IVP performed and CT scan was also performed which both
suggested UPJ obstruction. A nuclear medicine renogram was performed
in January 2004 which showed a differential function of 33% on the
right side.
The patient was admitted to the
hospital and underwent a right laparoscopic pyeloplasty and cystoscopy
with right retrograde pyelogram and right stent placement. She
was discharged to home in good condition.
Two weeks later she presented with
flank pain and it was discovered that the stent had migrated.
The original stent was removed and another was placed. She
returned three weeks later for stent removal.
The patient continued to have flank
pain postoperatively that did not respond to oral analgesics. A CT
scan was performed. This revealed an obstructed right kidney. A
nuclear medicine renogram was ordered:
Radiology Report:
Diuretic renogram dated 2/6/04.
A 32 year-old female with history
of right UPJ obstruction. The study is requested for evaluation.
Previous renogram was performed 11/24/03. The left system demonstrated
no obstruction. A smaller right kidney appears to be malrotated which
demonstrates partial clearance of the tracer. The functional curve was
done sloping. The differential function was 75 percent on the right
and 20 percent on the left.
10.4 mCi Tc-99m MAG 3. Dynamic images were obtained and framed at 3
second per frame intervals. This was followed by a renogram performed
for 40 minutes and images framed at 1 minute per frame. Computer
acquisition and time activity curves were performed.
The study demonstrates prompt uptake of the radiotracer in the left
kidney. The right kidney is not seen on the dynamic images. The left
kidney demonstrates normal uptake and transit time through the kidney
with a prompt recurrence of radiotracer into the collecting system and
bladder. The right kidney again appears malrotated with the renal
pelvis appearing lateral. There is increasing counts seen within the
right kidney which demonstrates very poor clearance over the course of
the study. Time activity curves were generated and demonstrate normal
washout on the left but steadily increasing counts on the right. The
functional curve is upsloping. This is a significant change from the
previous study. The differential function today measures 82 percent on
the left and 18 percent on the right. This also has diminished from
previous.
IMPRESSION: FINDINGS CONSISTENT WITH OBSTRUCTION OF THE RIGHT KIDNEY
AND COLLECTING SYSTEM. THIS APPEARS TO HAVE CHANGED FROM THE PREVIOUS
STUDY OF 11/24/03. CLINIC WAS NOTIFIED OF THE RESULTS.
A discussion was held with the patient
concerning treatment options. The options were to do nothing, a repeat
open pyeloplasty, versus nephrectomy. The patient wished to only have
one surgery to correct her problem.
The patient went to surgery on 2/13/04
where a right pyeloplasty was attempted; however, once the kidney was
fully inspected, it appeared to be not functioning and full of clear,
cloudy fluid. It was elected to perform a nephrectomy at that time.
Cultures were obtained from the wound. All culture growths were
negative. The patient remained on Unasyn and gentamicin throughout her
hospital course. Postoperatively, her vital signs remained stable. Her
creatinine remained good at 0.9. She was started on a regular diet on
postoperative day #2 and her PCA was stopped. She was not eating very
well, on postoperative day #3. She also complained of severe left
sided neck pain since the operation. Neurology evaluated the patient
and recommended Vioxx. The patient's pain improved. On postoperative
day #4, the patient's vital signs were stable. She was tolerating a
regular diet. Her bowels were moving. Her pain was under good control
and her pain had resolved. She was determined to be ready for
discharge.
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© 2003 Nuclear Education Online
Images courtesy of UAMS Dept of
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