A 46-year-old woman being evaluated for irregular vaginal bleeding is found to have invasive cervical carcinoma. She undergoes total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pelvic lymphadenectomy was also performed, during which several enlarged nodes around the pelvic vessels were resected. A week after the surgery, the patient begins to experience left-sided flank pain that radiates to the groin. Her temperature is 36.1 C (97 F), blood pressure is 120/70 mm Hg, and pulse is 84/min. On physical examination, there is a ballotable left flank mass. Which of the following most likely accounts for this physical examination finding?

Question

A 46-year-old woman being evaluated for irregular vaginal bleeding is found to have invasive cervical carcinoma.  She undergoes total abdominal hysterectomy and bilateral salpingo-oophorectomy.  Pelvic lymphadenectomy was also performed, during which several enlarged nodes around the pelvic vessels were resected.  A week after the surgery, the patient begins to experience left-sided flank pain that radiates to the groin.  Her temperature is 36.1 C (97 F), blood pressure is 120/70 mm Hg, and pulse is 84/min.  On physical examination, there is a ballotable left flank mass.  Which of the following most likely accounts for this physical examination finding?

Quizplus · Accepted Answer

11ec160b_3a52_5b9f_9249_6771850ccc05_MD0001_00 Flank pain radiating to the groin with a ballotable (ie, palpatable between both hands) flank mass that develops within a week of pelvic surgery suggests ureteric obstruction. The ureter runs in close proximity to the pelvic vessels. It courses anterior to the iliac vessels (area of resection of the pelvic nodes, which drain the uterus and cervix) and just posterior to the uterine artery near the lateral fornix of the vagina. It is vulnerable to injury during pelvic surgery, such as that involved in hysterectomy with pelvic lymphadenectomy. Unintentional ureteral ligation causes obstruction with hydronephrosis and flank pain due to distension of the ureter and renal pelvis. Urine output and serum creatinine remain within normal limits in most individuals with unilateral obstruction because the contralateral kidney functions normally and compensates for decreased functioning of the affected kidney. (Choice B) Acute interstitial nephritis is classically medication induced. Signs and symptoms include fever, transient rash, and acute renal failure. (Choices C and D) Renal cell carcinoma classically causes hematuria, flank pain, and a palpable mass. Adult polycystic kidney disease is an autosomal dominant condition characterized by multiple renal, pancreatic, and hepatic cysts. This patient had no evidence of a renal mass prior to surgery, and these conditions would not develop over a period of a week. (Choice E) Postsurgical patients are at increased risk for deep venous thrombosis, mostly in the lower extremities or pulmonary vasculature. Renal vein thrombosis is unusual postoperatively but may be seen in patients with nephrotic syndrome. (Choice F) Vesicoureteral reflux can be a complication of prostatectomy or bladder surgery. It predisposes to pyelonephritis and hydroureteronephrosis. Educational objective: The ureters run in close proximity to the pelvic lymph nodes and the uterine artery in the female pelvis, which predisposes them to injury during pelvic surgery.

A 46-Year-Old Woman Being Evaluated for Irregular Vaginal Bleeding Is