Introduction and Background

Figure 1. CT scan with residual stone in right ureteral stump.

After performing nephrectomy, the distal ureteral remnant is usually abandoned with no major complications,¹ but in a few patients this remnant may generate symptoms. Ureteral stump syndrome (USS) is a rare but well-known complication that occurs in patients after nephrectomy. These symptoms may appear between months and years after nephrectomy, and they include urinary tract infection (UTI), hematuria, and back pain or low abdominal pain.²

Figure 2. Retrograde pyelography with contrast leak.

When suspected, diagnosis is easily reached with routine imaging tests such as CT scan.^1,2 Usual treatment consists of resection of the ureteral remnant, but endourological approaches may be an option in some cases.¹ We describe a case of USS after a nephrectomy performed because of pyonephrosis.

Case Report

A 28-year-old female patient was received in our center with 14 days of right flank pain and fever. She had a history of urolithiasis and long-term UTI. CT scan evidenced severe right hydronephrosis and multiple homolateral kidney stones distributed in the lower and upper calyces. Serum creatinine was 1.4 mg/mL. Urine culture was obtained and antibiotic therapy was instituted with piperacillin-tazobactam, with unfavorable results.

Figure 3. Resected ureteral stump.

Open right radical nephrectomy was performed. During the procedure, pyonephrosis and severe inflammatory compromise of perinephric tissues were found. After surgery, the patient had good recovery, with hospital discharge after 7 days.

Three months after surgery, the patient experienced recurrence of right flank pain, hematuria, and UTI. CT scan was performed and a stone in the ureteral stump was found with no other pathological findings (Figure 1).

An endourological approach was selected. Retrograde pyelography was performed and severe leakage was found at low-pressure contrast instillation (Figure 2). With these findings, ureteroscopy was not performed, and laparoscopic ureteral stump resection was proposed.

During the laparoscopic approach, multiple adhesions were found and open surgery was selected. The ureteral stump was completely resected (Figure 3). After 4 days, the patient was discharged with good recovery. Six months after stump resection, the patient was in good clinical condition with symptom remission.

Discussion and Literature Review

After performing nephrectomy, the distal ureteral remnant is usually abandoned with no major complications. However, regarding the distal ureter, an unsubstantiated adage exists: “Take the ureter as far down as you can.” Complete removal of the ureter minimizes the risk of future morbidity associated with the distal ureteral stump, including febrile UTIs, lower quadrant pain, and hematuria, which comprise USS, although recurrent bacteriuria, hematuria, stones, and even malignancy can also be part of the syndrome.³ Urine reflux in the ureteral stump occurs due to poor drainage from the stump.⁴ Short ureteral stumps drain urine effectively by retained peristaltic activity, and thus USS is less likely to develop in short ureteral stumps.⁵

There have only been a few series showing the natural history of the ureteral stump after nephrectomy and partial ureterectomy in a solitary collecting system.⁵ Androulakakis et al suggested that long ureteral stumps act like a bladder diverticulum and predispose patients to developing USS.⁵ Performing retrograde ureterography or direct full visualization of the ureteral stumps before proceeding with the intended mode of treatment would help to predict the onset of subsequent symptoms. Although very uncommon, a genuine risk of ureteral stump cancer exists and must be evaluated.⁵

Usual treatment consists of resection of the ureteral remnant by open or laparoscopic technique. Endoscopic methods include sub-ureteral injection of polytetrafluoroethylene (Teflon)/dextranomer/hyaluronic acid, or endoscopic fulguration and fibrin glue occlusion of the ureteral lumen.⁶ Any of these procedures may potentially be used at initial nephrectomy or reserved for the small number of patients with symptoms attributed to the stump postoperatively.⁷

Surgical removal of the symptomatic distal ureteral stump is safe and effectively relieves symptoms. With a small incision in the groin, good exposure of the ureteral stump is obtained without opening the abdominal cavity, achieving complete resection of the stump. The laparoscopic approach has the advantage that there is no need for a second inguinal incision to handle the distal part of the ureter, such as with open surgery. However, it does not allow dissection of the stump to the bladder base.

Conflict of Interest: The Authors have no conflicts of interest to disclose.