Preoperative diagnosis - Septic shock; abdominal mass operation - ureterocystoscopy, right retrograde polygram. Postoperative diagnosis - massive right hydronephrosis.

With the patient in lithotomy position and under general anesthesia, the perineum was prepped with Betadine prep and then with Betadine and draped in an aseptic manner. A #23 french wappler cystourethroscope was introduced into the bladder. Urine was sent for culture and sensitivity. Exam of the bladder using the #23 french cystoscope and 60 degree lateral telescope revealed essentially normal mucosa with no efflux coming from the right ureteral orifice. A #5 french ureteral catheter was inserted to 15 cm and hydronephrotic drip was encountered. Plain film and injection films with up to 75 cc's of contrast showed the catheter coiled in the soft tissue mass. The injection film demonstrated a massive right hydronephrosis going all the way up to the kidney with what appeared to be very little renal parenchyma present. There was no gross pus but the urine appeared to be cloudy in appearance and foul smelling. The ureteral catheter was left indwelling and stented to a #16 french foley catheter. Dr. DiDonato and Dr. St. Jean then proceeded with abdominal exploration.

OR RIGHT RETROGRADE PYELOGRAM AND IVP: Subsequently six films were obtained in the operating room during performance of an operating room retrograde pyelogram and intravenous pyelogram. Several films outline a massively dilated collecting system of pelvis and visualized proximal ureter. Some contrast outlines the distal ureter which appears to be normal in caliber, presumably, although the nature of this obstruction cannot be evaluated on the examination.

Impression: Massive dilated right renal collecting system and proximal right ureter as demonstrated on retrograde study and intravenous pyelogram performed in the operating room. Computerized tomogram might be helpful in evaluating the nature of this obstruction.

ULTRASOUND EXAMINATION OF THE RIGHT FLANK:There is a septated fluid collection in the renal bed which measures 7 by 4 cm in diameter. This could represent a localized hematoma or celoma in this patient who is status post nephrectomy. If clinical condition warrants, follow up examination using C.T. might provide additional information owing to the presence of bandages and surgical staples.

Impression: Fluid collection is noted in the renal sulcus as discussed. G. Newstead, MD/DON/LB

LEFT RENAL SONOGRAM:The left kidney is moderately well demonstrated by ultrasound. There is considerable enlargement of the kidney which measures 14.58 cm in length and 7.58 cm. in AP diameter. No focal mass is seen. There is no dilation of the central renal collecting system. There is no previous ultrasound examination of the left kidney for comparison; however, IVP obtained in the operating room on 7/10/94 shows that the left renal outline was not enlarged at that time with a left renal length on that previous study of approximately 11. Scanning of the right renal outline fossa shows no definite collection at the right renal fossa on the present study.

Impression: (1) Enlargement of the left kidney with no evidence to suggest obstruction. This appearance suggests swelling, possibly due to edema. Compensatory hypertrophy would be less likely, given the short time interval since the right nephrectomy. (2) Evidence of satisfactory resolution of the right renal fossa hematoma.

RENAL PERFUSION SCAN:mmediately following the intravenous bolus administration of 28mci of 99 MTC GH, the patient's upper back is scanned and there is immediate visualization of the aorta, iliac arteries and immediate perfusion of the left kidney. Subsequent static scans show the left kidney to be normal in size, shape and position. However, localized increased activity is noted corresponding to the superior calix of this kidney which may indicate pyelectasis.

Impression: Absent activity in the right kidney area which may be due to previous surgery. Normal perfusion of the left kidney, but possible pyelectasis involving the superior calix of the left kidney. V. Erburg, MD/NS/SC