A 52-year-old woman with extensive pelvic ovarian cancer comes to the emergency department because of difficulty with urination. She has noticed decreasing urine volumes for the past two weeks. She denies dysuria, hematuria, or flank pain. Her other medical problems include hypertension and type 2 diabetes. Her current medications include metformin and lisinopril. She has had no urine output over the last 12 hours.
Her blood pressure is 142/70 mm Hg and pulse is 89/min. Lungs are clear on auscultation. Her abdomen is modestly distended and demonstrates fullness in both lower quadrants without a discrete mass. She has 2+ pitting bilateral lower extremity edema to the mid-shin.
Laboratory results are as follows:

Insertion of a Foley catheter yields no urine. An ultrasound reveals grade 3 bilateral ureteric dilation. A urology consultant is able to advance pigtail catheters into both ureters from the bladder. Her urine output after catheter insertion improves to 600 cc/hr over the next two hours.
Which of the following is the best next step in management for this patient?

Question

A 52-year-old woman with extensive pelvic ovarian cancer comes to the emergency department because of difficulty with urination.  She has noticed decreasing urine volumes for the past two weeks.  She denies dysuria, hematuria, or flank pain.  Her other medical problems include hypertension and type 2 diabetes.  Her current medications include metformin and lisinopril.  She has had no urine output over the last 12 hours.
Her blood pressure is 142/70 mm Hg and pulse is 89/min.  Lungs are clear on auscultation.  Her abdomen is modestly distended and demonstrates fullness in both lower quadrants without a discrete mass.  She has 2+ pitting bilateral lower extremity edema to the mid-shin.
Laboratory results are as follows:

Insertion of a Foley catheter yields no urine.  An ultrasound reveals grade 3 bilateral ureteric dilation.  A urology consultant is able to advance pigtail catheters into both ureters from the bladder.  Her urine output after catheter insertion improves to 600 cc/hr over the next two hours.
Which of the following is the best next step in management for this patient?

Quizplus · Accepted Answer

11ec193a_96a9_0773_853d_f36b34c6d4d0_MD0002_00 This patient has bilateral obstructive uropathy from extensive ovarian cancer and now presents with post-obstructive diuresis. Partial bilateral urinary obstruction usually results in normal to slightly increased urine volume, possibly due to renal tubular damage and secondary concentrating defect. As a result, patients with renal failure and urine output >1 L/day may still have significant obstructive uropathy. However, complete bilateral obstruction usually causes anuria (as in this patient). Relief of complete bilateral urinary obstruction usually leads to post-obstructive diuresis (mechanisms shown in the above table) as the kidney attempts to excrete the retained fluid. Patients can have a urine output of 500-1000 cc/hr, which is considered appropriate polyuria. Some volume repletion is required to prevent sodium wasting, hypotension, or worsening volume depletion. However, attempts to completely or nearly match the urine volume lead to overall volume expansion and even worse diuresis, up to 10 L/day (Choices A, B, and C). There are no controlled studies to guide management; however, most experienced clinicians replace the patient's body volume with either isotonic or half normal saline at a rate <50% of urine volume (eg, ~200 cc/hr in this patient with urine output ~600 cc/hr) and adjust the rate based on the patient's response and subsequent volume status. (Choice D) The kidney generally does not respond to vasopressin after relief of chronic urinary tract obstruction, and DDAVP will likely not decrease the rate of diuresis. Educational objective: Chronic partial bilateral urinary obstruction can result in normal or slightly increased urine volume, while complete bilateral obstruction causes anuria. Relief of the obstruction leads to post-obstructive diuresis (500-1000 cc/hr) that can be worsened by trying to match volume repletion with urine output. Treatment usually involves volume repletion at a significantly lower rate than urine volume loss. __________ References: Diuresis and renal functional recovery in chronic retention. (http://www.ncbi.nlm.nih.gov/pubmed/3971092) Ovarian cancer causing upper and lower urinary tract obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/7828602)

A 52-Year-Old Woman with Extensive Pelvic Ovarian Cancer Comes to the Emergency