A 50 years old female is admitted with abdominal pain and anuria. Radiological studies revealed: bilateral impacted ureteric stones with hydronephrosis. Urine analysis showed RBCs with pus cells in urine. Serum creatinine level was 16 mg/dL and urea level was 200 mmol/L. Which of the following should be the immediate treatment?

**Core Concept**
The patient is suffering from bilateral ureteric obstruction due to impacted stones, leading to severe renal impairment and acute kidney injury (AKI). The primary goal of treatment is to relieve the obstruction, stabilize renal function, and prevent further damage.

**Why the Correct Answer is Right**
The immediate treatment for bilateral ureteric obstruction and AKI is **percutaneous nephrostomy (PCN)**. This involves inserting a catheter through the skin and into the kidney to drain the urine and relieve the obstruction. PCN is particularly useful in this case as it allows for rapid decompression of the obstructed kidneys and can be performed urgently. This is crucial in preventing further renal damage and improving renal function.

**Why Each Wrong Option is Incorrect**
**Option A:** **Ureteric stenting** may be a useful adjunct to PCN, but it is not the primary treatment for bilateral ureteric obstruction and AKI. Stents can become dislodged, and multiple stents may be required, making PCN a more reliable option.
**Option B:** **Pain management** is important, but it does not address the underlying cause of the renal impairment. While pain control is essential, it is not the immediate treatment for AKI.
**Option C:** **Medical expulsive therapy** with alpha-blockers or calcium channel blockers may help in passing smaller stones, but it is not effective in relieving bilateral ureteric obstruction and AKI.

**Clinical Pearl / High-Yield Fact**
In cases of bilateral ureteric obstruction and AKI, timely PCN can significantly improve renal function and outcomes. It is essential to recognize the need for urgent intervention to prevent long-term renal damage.

**Correct Answer:** .

✓ Correct Answer: B. 'j' stent drainage