Symptomatic Hydronephrosis
with History of Colon Carcinoma

This case demonstrates an interesting clinical scenario with likely recurrent colon cancer causing unilateral hydronephrosis. The initial abdominal CT showed a two centimeter lesion at the mid-sacral level of the left ureter (figure 3). At that time, the patient had vague left lower quadrant pain and mild symptoms of colonic obstruction. The options were: 1) retrograde placement of an internal left ureteral stent, 2) percutaneous neprostomy drainage of the left kidney, and 3) observation. The options were discussed with the patient. He did not want to undergo anesthesia for stent placement and was opposed to percutaneous drainage because he believed that his lifestyle would be limited by a nephrostomy bag. It was felt that for an informed patient who did not require bilateral renal funtion for further chemotherapy, it would be reasonable to observe, allowing the hydronephrosis to persist with possible sacrifice of left renal function.

After ten days of conservative therapy, the patient returned with complaints of intermittent left flank pain. Repeat abdominal CT clearly demonstrated ongoing left hydronephrosis with a new forniceal ruture and formation of a large urinoma (figure 4). With the patient still adamantly opposed to intervention, the patient and physician elected to observe for several more days. Five days later, the patient underwent retrograde placement of a left double J internal stent for persistent pain. A stent is not ideal therapy for external compression, and frequent changes secondary to lumenal occlusion by urinary sediment can be expercted. However, the patient continues to state that he would prefer a nephrectomy to a percutaneous nephrostomy.