Acute Obstructive Uropathy with Anuria Due to Bilateral VUJ Calculi in a Young Male: Acute bilateral ureteric obstruction leading to anuria and acute kidney injury is a urological emergency requiring prompt diagnosis and intervention to prevent permanent renal damage. We report a case of a 23-year-old male presenting with bilateral flank pain and anuria, found to have bilateral vesicoureteric junction (VUJ) calculi with acute obstructive nephropathy, successfully managed with emergency bilateral laser ureteroscopy (URS) and double-J (DJ) stenting.
Introduction
Obstructive uropathy due to bilateral ureteric calculi is an uncommon but life-threatening condition, particularly in young adults. Delay in recognition and intervention can result in severe acute kidney injury, electrolyte imbalance, and systemic complications. Early decompression of the urinary tract is crucial to restore renal function and prevent long-term sequelae. Advances in endourology now allow definitive management even in complex emergency settings.
Case Presentation
A 23-year-old male presented to the emergency department with complaints of bilateral flank pain and complete anuria for the past three days. The pain was severe, colicky, and progressive in nature. There was no history of trauma, fever, lower urinary tract symptoms, or prior surgical intervention. No significant comorbidities were reported.
On examination, the patient appeared ill but was hemodynamically stable. Abdominal examination revealed bilateral flank tenderness. Bladder was clinically empty.
Investigations
Initial laboratory evaluation revealed:
- Serum creatinine: 8.36 mg/dL, suggestive of severe acute kidney injury
Ultrasonography (USG) of the abdomen showed:
- Bilaterally mildly bright kidneys
- Bilateral mild hydroureteronephrosis, suggestive of obstructive uropathy
- Empty urinary bladder
- Minimal ascites
- Minimal bilateral pleural effusion
Non-contrast CT KUB (NCCT KUB) revealed:
- Mild bilateral hydroureteronephrosis
- Bilateral VUJ calculi
- Left nephrolithiasis
- Enlarged, globular, hypoattenuating bilateral kidneys suggestive of acute obstructive nephropathy
- Mild ascites
- Mild left and minimal right pleural effusion with left basal atelectasis
Additional investigations:
- ECG: Within normal limits
- Chest X-ray: No active disease
Diagnosis
Based on clinical presentation and radiological findings, a diagnosis of acute bilateral obstructive uropathy due to bilateral VUJ calculi causing anuria and acute kidney injury was established.
Management and Surgical Procedure
Given the severity of obstruction and rising creatinine levels, urgent surgical intervention was planned. The patient and his relatives were thoroughly counselled regarding the condition, need for emergency decompression, surgical risks, and expected outcomes.
The patient underwent:
- Cystoscopy
- Bilateral laser ureteroscopy (URS)
- Bilateral DJ stenting
under general anesthesia.
Intraoperative Findings
- Cystoscopy revealed a normal urethra and bladder neck
- Right URS:
A 4 Fr ureteroscope was introduced. An impacted lower ureteric calculus was encountered. The guidewire could not be negotiated beyond the stone. The stone was successfully fragmented using laser lithotripsy, following which a right DJ stent was placed. - Left URS:
An impacted lower ureteric calculus was identified. The 4 Fr ureteroscope was negotiated with difficulty. Laser fragmentation was performed successfully, and a left DJ stent was placed. - The patient was catheterized at the end of the procedure.
The patient tolerated the procedure well with no intraoperative complications.
Postoperative Course
The postoperative period was uneventful. Urine output improved significantly following the procedure, indicating relief of obstruction. Renal parameters showed gradual improvement on follow-up monitoring. The patient remained clinically stable and was managed with close biochemical and clinical surveillance.
Follow-Up Plan
- Catheter removal after 7 days
- CBC and serum creatinine monitoring at 3, 7, and 10 days
- Review after 6 weeks for bilateral DJ stent removal and check URS under anesthesia
- Metabolic evaluation planned after 2 months to identify underlying risk factors for stone disease and prevent recurrence
Discussion
This case highlights the critical importance of early recognition and urgent intervention in patients presenting with anuria and bilateral obstruction. Symptoms can rapidly progress to life-threatening renal failure if not managed promptly. Bilateral impacted distal ureteric stones pose significant technical challenges, especially in emergency settings, requiring advanced endourological expertise.
Definitive management with bilateral laser URS and DJ stenting not only relieved obstruction but also allowed preservation and recovery of renal function. Comprehensive post-procedural planning, including metabolic evaluation, is essential in young stone formers to prevent recurrence.
Institutional Expertise and Clinical Excellence
This complex emergency case was successfully managed at the Institute of Urology (IOU), Jaipur, a single-speciality, tertiary care urology hospital and one of the most advanced urology centers in Jaipur and Rajasthan. IOU is fully equipped with state-of-the-art endourology suites, advanced imaging, critical care support, and round-the-clock emergency urology services.
The institute’s core focus is to maintain the highest standards of treatment, patient safety, and compassionate care across all urological subspecialties, including complex stone disease, renal failure, and obstructive uropathy.
Under the expert leadership of Dr. M. Roychowdhury and Dr. Rajan Bansal, senior urologists with vast experience in managing high-risk and complicated urological emergencies, this patient received timely, evidence-based, and definitive care. Their expertise in advanced endourological procedures such as laser URS, PCNL, RIRS, and emergency decompression plays a pivotal role in achieving excellent outcomes even in critically ill patients.
Conclusion
Acute bilateral obstructive uropathy presenting with anuria and renal failure is a urological emergency that demands rapid diagnosis and expert intervention. This case demonstrates that with timely surgical management and specialized care, even severe obstructive nephropathy in young patients can be successfully reversed. Dedicated centers like the Institute of Urology, Jaipur, with experienced urologists and advanced infrastructure, are crucial in managing such life-threatening urological conditions effectively.
