A FRCS Urol station on MedMock, start to finish

Good morning. We'll discuss some emergency scenarios. The first: you're the consultant urologist on call. A 46-year-old woman is admitted with two days of right loin pain, fever and rigors. Her temperature is 39.4, her heart rate 120, and her blood pressure 86 over 50 after a fluid bolus. Her creatinine is 148 and her lactate 4.1. A non-contrast CT shows a 7 millimetre stone in the right proximal ureter, with moderate hydronephrosis and perinephric stranding. How would you manage her?

She has an obstructed, infected kidney with septic shock. That's a urological emergency: she needs resuscitation, antibiotics and urgent decompression, and the stone itself can wait. I'd see her straight away and involve critical care now, because she's hypotensive after fluid and her lactate is over 4. Blood and urine cultures, then broad-spectrum intravenous antibiotics within the hour according to our sepsis guideline; further fluid against her response, and early vasopressors on critical care; a catheter and hourly urine output; and a pregnancy test, clotting and a group and save. Then decompression of the right kidney as an emergency, tonight, not on the next list. There are two ways to do it: a percutaneous nephrostomy or a retrograde ureteric stent. The EAU guideline regards them as equally effective: the systematic reviews show no difference in success, complications or time to defervescence, although a nephrostomy tends to mean a longer stay and a stent causes more symptoms afterwards. So the choice is practical: which is available fastest and safest for her. A nephrostomy can be done under local anaesthetic, which is attractive when she's shocked, but it needs acceptable clotting and an interventional radiologist; a stent needs theatre and usually a general anaesthetic, but is better if she's coagulopathic. What I wouldn't do is treat the stone: no ureteroscopy in an infected, obstructed system. I'd send urine from the kidney for culture at the time of decompression, adjust the antibiotics to the results, and leave definitive treatment until the sepsis has resolved and she's completed her antibiotics.

Thank you. It's two in the morning. Interventional radiology can't do a nephrostomy until the morning, and she's now on noradrenaline in critical care. What do you do?

She can't wait until the morning, so I'd take her to theatre now for a retrograde stent, having discussed the risks of an anaesthetic on noradrenaline with the consultant anaesthetist. In theatre: a cystoscopy, a guidewire passed gently up past the stone under fluoroscopy, then an open-ended ureteric catheter over the wire above the stone to aspirate urine from the kidney for culture, and a double-J stent. I'd keep manipulation and contrast to a minimum and avoid injecting under pressure, because pushing infected urine back into the kidney can make the sepsis worse. If the wire won't pass the stone, I wouldn't force it: she'd need a nephrostomy that night, so I'd speak to the on-call interventional radiologist directly, or arrange transfer to a unit that can do it. I'd leave a urethral catheter so the bladder drains freely at low pressure, send her back to critical care, and speak to her family.

Thank you. She recovers. A week later she's well and has finished her antibiotics. How would you deal with the stone?

First I'd check where it is with a non-contrast CT, because it may have moved or passed. If it's still in the proximal ureter, the options are shockwave lithotripsy or ureteroscopy. For ureteric stones under 10 millimetres, NICE recommends offering shockwave lithotripsy first, with ureteroscopy if lithotripsy isn't suitable or won't clear the stone within four weeks. With a stent already in and a recent infection, I'd discuss both with her; many would choose ureteroscopy and laser fragmentation, because it clears the stone in one procedure and lets the stent come out, with antibiotic cover based on her culture. NICE advises against routinely leaving a stent after an uncomplicated ureteroscopy for a stone this size, though after an infected obstruction I'd have a lower threshold. Then I'd send the stone for analysis, check her serum calcium, and give her advice on preventing recurrence, particularly drinking enough water.

Thank you. The second scenario. You're called urgently to a gynaecology theatre, where a colleague is doing an open hysterectomy for a large fibroid uterus in a 47-year-old woman. While controlling bleeding near the left uterine artery, they think they've injured the left ureter. What do you do?

I'd go straight there, scrub, and ask them not to do anything further to the ureter, including clamping or tying anything else near it. First I'd check with the anaesthetist that she's stable and how much blood she's lost. Then I'd find out exactly what happened: a clamp, a suture, diathermy or a cut, and when. I'd find the left ureter where it's normal, usually where it crosses the iliac vessels, and trace it down to the injury to see what kind it is, whether a ligature, a crush, a partial or complete division, or a thermal injury, and its level and length. I'd also check the right ureter and the bladder, because a second injury is easily missed, for example with a cystoscopy to watch for efflux from both ureteric orifices, or by filling the bladder to look for a leak. A ligature recognised straight away can be removed and a stent placed if the ureter looks viable, and a small partial injury can be repaired over a stent. Whatever I find, I'd document it carefully.

Thank you. You find the left ureter has been completely divided about 4 centimetres above the bladder, and the ends are crushed. She's stable. How would you repair it?

A complete division recognised during the operation should be repaired now: the EAU recommends immediate repair, which means fewer further procedures than a delayed repair. This is a distal injury, so I'd reimplant the ureter into the bladder rather than join the two ends, because the blood supply to the distal ureter is already compromised. I'd debride the crushed end back to healthy, bleeding ureter, tie off the distal stump and mobilise the bladder. A psoas hitch, fixing the bladder to the psoas tendon, usually bridges the gap and takes the tension off the anastomosis, and if I need more length I can divide the contralateral superior vesical pedicle. The anastomosis should be spatulated, tension-free and watertight, mucosa to mucosa with fine absorbable sutures, over a double-J stent, with a drain, and covered with peritoneum or omentum where possible. Whether to make it refluxing or non-refluxing is still debated; in an adult I'd accept a simple refluxing reimplant rather than risk narrowing it with a tunnel. A Boari flap gives more length, but it's a longer operation and less suited to the acute setting. Afterwards: a urethral catheter for around ten days, with a cystogram before it comes out, the stent out at around six weeks, and imaging after that to confirm the kidney drains well.

Thank you. What if the injury hadn't been recognised, and on the fifth day after the operation she developed a fever, left flank pain and watery fluid leaking from the wound?

Then I'd assume a urine leak until proved otherwise. I'd resuscitate her and treat any sepsis, send the wound fluid for creatinine to compare with her serum level, and get a CT urogram with delayed images to show the leak, any obstruction or urinoma, and whether the other ureter and the bladder are intact. For an injury found late, the EAU recommends urinary diversion first: a nephrostomy, with an attempt to pass a stent down through it, or a retrograde stent, and I'd drain any urinoma. Small injuries can heal over a stent. If a stent can't be passed, or a stricture develops, she'll need a formal reconstruction, usually once the inflammation has settled. She also needs to be told honestly what has happened. The gynaecology consultant, as the operating surgeon, should lead that conversation, with me there. It's likely to meet the threshold for the statutory Duty of Candour, which means an apology, an account of what we know, what happens next and a written follow-up, and we all have a professional duty of candour anyway.

Thank you. That's the end of the station.