Immediate Definitive Interventions

If no indications exist for temporary drainage procedures, immediate definitive therapy can be considered. Use of immediate definitive therapy is more common when the cause of flank pain is urinary calculi and only considered when partial upper tract obstruction is present. In this scenario, the size, number, and location of the stones impact the choice of endourologic treatment. Immediate management of partially obstructing stones in the kidney and ureter should follow the recommendations set forth in the AUA nephrolithiasis treatment guidelines (Preminger et al. 2005; Segura et al. 1997). In reality, advances in endoscope design and instrumentation make ureteroscopic approaches to these problems much more appealing than ever before. An additional benefit of ureteroscopic treatment in the setting of acute management with partial obstruction is the ability to assess intraoperatively for unrecognized infection or contributing abnormalities such as ureteral stricture. Also, if circumstances are encountered that make urete-roscopy less optimal in the acute setting, the threshold should be low for stenting the patient and returning at a later date for definitive treatment.

In the setting of life-threatening urinary tract infections such as emphysematous pyelonephritis with obstruction, temporary drainage procedures may provide suboptimal treatment. Nickel has noted that relief of obstruction and antibiotics are usually sufficient treatment, but that nephrectomy should be considered in non-responders (Nickel 2002). Since the contemporary mortality rate remains approximately 75 % for the typical diabetic patient that develops emphysematous pyelonephritis (Nickel 2002), we favor immediate traditional treatment with nephrectomy rather than an initial trial of temporary drainage.

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