Persistent ureteric stump syndrome post ureteric re-implantation following impacted distal ureterolithiasis: Experience from tertiary hospital. Case report

Introduction and importance: Ureteric stump syndrome [USS] is a series of febrile recurrent lower abdominal pain, urinary tract infections, and hematuria that sometimes present with empyema as a rare complication. The ureteric stump is left after ureteric re-implantation due to an impacted stone at the Vesical-ureteric junction [VUJ], or after nephrectomy of a non-functional kidney due to a distal stone; the ureteral stump forms a source of infection to the urinary bladder, in addition to long-term obstructive stones left at the ureteric stamp. This usually cause chronic irritation of the mucosa and potentially change to metaplasia, dysplasia and malignancy. On a standard protocol, in upper urinary tract, transition cell carcinoma [TCC], because of its multifocality, nephrectomy is performed along with ureterectomy to the level cuff of the urinary bladder en block resection, but not in the case of a non-functional kidney where the proximal ureterectomy is performed, and a potential ureteric stump is left in a patient, whom later on presents with recurrent febrile lower urinary tract symptoms. It is important to exclude ureteric stump syndrome after nephrectomy or ureteric re-implantation. The need for surveillance of the ureteric stump is of paramount important.

Case presentation: A patient aged 66 yrs., female presented with right flank pain for one year, colick in nature, radiating to the lower abdomen and genitalia and was associated with nausea and vomiting. The patient was yet experiencing a recurrence of lower abdominal pain and repeatedly being diagnosed with recurrent urinary tract infection for the past 6 months after ureteric re-implantation. Several blood tests showed leukocytosis and urine culture revealed Pseudomonas, and the patient was given antibiotics. Symptoms resolved after the administration of antibiotics, and after a while symptoms subsequently recurred again. The patient was then scheduled for retrograde ureteroscopy of the native ureter and uretero-renoscopy (URS) of the neo-ureterocystostomy (neo-reimplanted ureter). Intraoperative findings were an impacted distal ureterolithisias of the native ureter, with debris that was subsequently fragmented with rigid uretero-renoscopy [URS] and contact lithotripsy. The re-implanted ureter was surveyed and found to have good patency.

Clinical discussion: Recurrent febrile urinary tract symptoms, hematuria, and lower abdominal pain are associated with ureteric stump syndrome in a patient after nephrectomy and proximal ureterectomy post-ureteric re-implantation due to distal ureterolithiasis. A potential risk factor for our patient was an infected stone which was impacted at VUJ, that led to stasis of urine that was trapped due to obstruction. Radiological investigations that can be used to diagnose ureteric stamp syndrome include retrograde ureterography, cystography, and CT IVU, which reveal the thickening of the ureteral stamp wall and enhancement and, if it contains calculi, hyperdense foci in the plain phase. Complications such as psoas muscle abscess or the fistulization of ureteric stamps to the uterus. Management options for ureteric stump syndrome include surgical excision of the ureteric stump or a laparoscopy approach for distal ureterectomy; others can also include transurethral fulguration of the empyema ureteric stump. The URS is either flexible or rigid.

Conclusion: Complete resection of the ureteric stamp due to stones at the VUJ is of paramount importance, especially when a foreign body is left in situ, because of the potential for infections, termed ureteric stump syndrome. It is important to exclude ureteric stump syndrome after nephrectomy or ureteric re-implantation. Surveillance of the ureteric stump is of paramount important.