Bilateral obstructive uropathy following laparoscopic append
The following case appears in the Journal of Clinical Nephrology and Therapeutics.

A fifty-four-year-old male, with a metallic aortic valve on warfarin, presented with acute appendicitis. He underwent laparoscopic appendicectomy which revealed a necrotic appendix. Initial post-operative recovery was uneventful and he was discharged seven days following admission.

He represented three days after discharge with hypovolaemic shock and abdominal distension. CT abdomen/ pelvis showed rectus sheath haematoma with significant abdominal and pelvic extension. His warfarin was reversed and a bleeding inferior epigastric artery was controlled by embolisation by interventional radiology.

Over the subsequent days, he developed progressive renal impairment, with creatinine rising from a normal baseline on admission to 270 despite haemorrhage control, transfusion of packed red cells and adequate intravenous fluid resuscitation.
Repeat imaging revealed minimal fullness of his right renal collecting system and normal left collecting system.

Cystoscopy revealed a grossly distorted bladder due to extrinsic compression by the haematoma. The right ureteric orifice was identified and a right ureteric stent was placed day one of re admission. Due to abnormal anatomy, the left ureteric orifice could not be identified.

Despite the placement of a right ureteric stent, creatinine continued to rise. A nephrostomy tube was inserted the following day by interventional radiology and renal function subsequently improved. On day three of his readmission, the rectus sheath haematoma was drained by interventional radiology.

The patient recovered well following this and was subsequently discharged day thirty of readmission. Nephrostomy and ureteric stent were subsequently removed and renal function remained normal.

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