2019 Research Forum

Applicant & Principal Investigator: Tushar Bajaj MD R1 Faculty Sponsor: David Aguirre MD

Atypical Presentation of Obstructive Anuria

Tushar Bajaj MD R1, Hanh Duong MS III, David Holt MS III, Jasmine Ho PharmD, Sudhagar Thangarasu MD, David Aguirre MD

INTRODUCTION Anuria is defined as the urine output less than 50ml every 24 hours. A myriad of etiologies can lead to anuria including but not limited to renal impairment, urinary tract obstruction, drugs, or severe infections. Obstructive uropathy is a common cause of anuria that is easy to diagnose; however, we present a difficult diagnosis of an atypical patient who had a previous nephrectomy and a recent radical prostatectomy with a CT Abdomen and Pelvis without contrast that did not demonstrate a urinary stone or hydronephrosis. PURPOSE A 64 year old with a history of right nephrectomy (1986), prostate cancer (diagnosed 10/2018) status post radical prostatectomy (10/2018) presents to the emergency department for acute abdominal pain and 13 episodes of non-bloody non-bilious emesis for one day. At home, patient had a sudden onset of nausea and vomiting with abdominal pain. He describes it as sharp, intermittent, in the left mid-quadrant radiating to epigastric lasting 7 hours. Since his prostatectomy, patient has been incontinent of urine, but accompanying that initial episode of emesis, he noticed a cessation of urine production. On examination, patient was afebrile with diffuse abdominal tenderness, distension; no costovertebral tenderness. Laboratory results showed elevated BUN 34 and creatinine 2.82 without leukocytosis or lactic acidosis. A Foley catheter was placed and produced no urine. A total of 5 liters of fluid was given, but patient remained anuric. CT of abdomen and pelvis without contrast confirmed placement of Foley catheter and revealed perinephric stranding, multiple renal cysts without hydronephrosis. Radiographic cystogram was negative for mass lesions in the bladder and vesicoureteral reflux. 3 days later, patient continued to endorse diffuse abdominal pain with BUN and creatinine 62 and 8.03. Decision was made for placement of tunnel catheter for hemodialysis. Patient’s abdominal pain improved with BUN and creatinine to 51 and 8.20, but he was still anuric. Considering the availability of dialysis, patient had CT of abdomen and pelvis with contrast done with immediate hemodialysis after. It showed mild hydroureter and hydronephrosis with non-obstructive 3mm stone at the ureterovesicular junction, and ureteric sludge distally. Patient underwent stent placement in the OR. Immediately, patient had normal urine production, and improvement of renal function; BUN and creatinine trending downwards to 15 and 2.58 from 47 and 10.10 pre-operatively. DISCUSSION Anuria in the setting of obstructive uropathy was not clearly defined in our case. The initial images obtained through non-contrast CT and cystography failed to clearly demonstrate any obstruction. A CT with contrast would have further insulted our patient’s only remaining kidney. He required a tunnel catheter for urgent dialysis, which also allowed for a CT with contrast to be obtained which clearly demonstrated an obstruction. Once both images were able to be compared an obstruction was visible. CONCLUSION In our unusual presentation of obstructive anuria, our approach to treatment was challenged by patient’s worsening kidney function and insufficient evidence from imaging. Considering patient’s morbidity and necessity for immediate resolution, we should strongly consider dialysis to allow imaging with contrast to be done without fear of nephrotoxicity.

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