For patients with a normal urinary tract, we have favored an attempt at cystoscopy with retrograde ureter-al catheterization before trying percutaneous drainage techniques. When turbid urine is encountered at the time of retrograde catheterization, not uncommonly we will initially place an external ureteral catheter rather than immediately placing an indwelling double pigtail stent. This provides an opportunity to directly monitor the character of the drainage and can provide an option for flushing the catheter to maintain ade quate drainage. We typically use an open ended 6-F angiographic catheter for a patient requiring external drainage, but a variety of other open-ended ureteral catheters are also available for this purpose. The external catheter is fixed to the Foley catheter with suture and drained separately into an external collection device. This permits evaluation of the amount and nature of the drainage. When turbid urine is encountered, the fluid should be sent for culture. In addition, the presence of infection with obstruction also mandates urgent antibiotics. Typically, intravenous therapy is initiated with aminoglycosides with ampicillin, a fluoroquinolone, or a third-generation cephalosporin. Antibiotics are started before any manipulation of the obstructed upper urinary tract. While patients are in the hospital, we do aggressively hydrate our patients to induce a water diuresis. This can facilitate a mechanical washout of the upper tract. Based on culture results, antibiotic therapy is modified with a typical duration of therapy of 7-14 days (Nickel 2002; Kalyanakrishnan and Scheid 2005). When the patient's clinical picture improves, internalization of drainage is then performed by placing a double pigtail stent. For pregnant females needing urgent decompression, we traditionally have favored retrograde stent placement. For patients with a urinary diversion, renal allograft, or significant anatomic variation, urgent decompression at our institution is most commonly performed immediately with percutaneous drainage. After temporary drainage, individual clinical circumstances dictate the follow-up plan for further diagnostic or therapeutic intervention. When urgent drainage is performed for obstructing stones, a minimum of 2 - 3 weeks is allowed for complete treatment of concurrent infections and to permit resolution of obstruction-induced inflammation of the upper tract.
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