Ureteric obstruction: an unusual complication of total hip replacement

The patient presented at the age of 7 with osteomyelitis associated with avascular necrosis of the left femoral head. He was treated with subtrochanteric osteotomy to correct limb shortening. Fifty years later, a left total hip replacement was required. This was complicated by persistent low grade infection, resulting in three revisions of the arthroplasty over the subsequent 3-year period. Thirteen years after the original arthroplasty, he underwent a 'redo' left total hip replacement, with removal of the original infected prosthesis. Surgery was complicated by penetration of the acetabulum and damage to the internal iliac vein, resulting in haemorrhage. The defect in the acetabulum was closed with methacrylate cement. At this time, he was normotensive with a serum creatinine of 104 umol/1. He was discharged from follow-up 2 years later. He re-presented at the age of 73 (17 years after his initial arthroplasty) with hypertension and renal dysfunction (serum creatinine 299 umol/1). Renal ultrasonography revealed a 'minor degree of hydronephrosis of the left kidney'. He was noted to have a tight phimosis and underwent circumcision with perioperative cystoscopy. It was not possible to catheterize the left ureter because of 'obstruction'. The patient was subsequently lost to follow-up. One year later, hypertension was poorly controlled and renal function had deteriorated (serum creatinine 338 umol/1). Haematoproteinuria was also present (3 g protein/24 h). Ultrasonography revealed bilateral small echogenic kidneys, with gross hydronephrosis and ureteric dilatation on the left. A pelvic radiograph demonstrated a large radio-opaque mass, consistent with orthopaedic cement, protruding medially from the left acetabulum and into the pelvis (Figure 1). A left percutaneous nephrostomy was inserted. Nephrostogram revealed a tortuous dilated left ureter, tapering to complete obstruction within the pelvis, in close proximity to the arthroplasty cement (Figure 2). There was no passage of contrast into the lower bladder or ureter. An antegrade ureteric stent was passed with difficulty. Renal function continued to deteriorate and the patient was established on haemodialysis.