Pyelonephritis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]
Overview
Pyelonephritis is usually managed medically. In recurrent infections, additional investigations may identify an underlying abnormality like a stone, a tumor, or an underlying pathological process that has to be aggressively dealt with. Surgery is usually indicated in a patient who does not improve after 48 hours of IV antibiotics or deteriorates. Occasionally, surgical intervention is necessary to decrease of recurrence and to prevent devastating complications. Various renal conditions like obstructive pyelonephritis with presence of stones in the presence of an infected kidney can be fatal and requires urgent management.
Surgery
Surgery may be necessary in case of continuous deteriorating pyelonephritis, recurrent disease, renal failure or development of complications. Xanthogranulomatous pyelonephritis is often confused with renal tumor and is usually diagnosed after resection of the kidney and performing microscopic examination showing the inflammatory mass composed of lipid-laden macrophages and chronic inflammatory cells.The following kinds of surgeries can be associated with the management of pyelonephritis:[1][2][3][4][5]
Renal biopsy
- A biopsy can be done to confirm the diagnosis of a complex renal pathology or to check the extent and type of damage to the kidney.
- It is used specifically in case of xanthogranulomatous pyelonephritis that is confused with renal tumors usually Wilm's tumor.
- The histopathological exam of the biopsy specimen confirm xanthogranulomatous type of pyelonephritis.
Ureteroscopy
Flexible ureteroscopy is done for the treatment of obstructive pyelonephritis. It is very effective in removing large proximal placed ureteral stones that are greater than 1.5cm. It can be performed after drainage of an infected kidney to effectively remove renal stones. Flexible ureteroscopy has a stone free rate of almost 80%. It has advantages over Transperitoneal laparoscopic ureterolithotomy in that:[6]
- It causes less post operative pain
- Has a lesser hospital stay
- Early return to daily routine
Double J Stenting
Double J stenting, also known as DJ Stenting, is a conservative management method for emphysematous pyelonephritis. A nephrostomy tube or DJ stunt can be used to decompress the urinary tract which may be enlarged secondary to various reasons like a tumor or an obstructing stone.[7][8]
Percutaneous nephrostomy
Percutaneous nephrostomy is an effective treatment option for emphysematous pyelonephritis which is characterized by necrotizing damage to the parenchyma of the kidney and its adjoining tissue leading to gas formation. Percutaneous nephrostomy should be accompanied by adequate hydration and glycemic control.[7]
Nephrolithotomy/Ureterolithomy
Percutaneous nephrolithotomy or transperitonial laproscopic ureterolithotomy (TLU) are effective surgical treatment options for pyelonephritis. TLU is effective in removing large ureteral stones with a very high stone free rate approaching upto 100%.[6]
Partial Nephrectomy
- A partial nephrectomy is performed in case of a localised renal pathology. It can also be done in case of low grade real disease that is resistant to medical management.
- Partial Nephrectomy involves excising only the involved segment of the kidney leaving behind the healthy part of the kidney.
Nephrectomy
- Nephrectomy is considered in case the renal involvement is diffuse or the damage to the kidney is in an advanced stage.
- Nephrectomy may also be required in cases of severe complications.
Vacuum Sealing Drainage
Emphysematous pyelonephritis can be treated with a vacuum sealing drainage. A vacuum sealing drainage (VSD) sponge is tailored and placed around the kidney ensuring no dead space is present. A negative low pressure helps drain the pus and the gas present in case of emphysematous pyelonephritis.[9]
References
- ↑ Kanno T, Matsuda A, Sakamoto H, Higashi Y, Yamada H (2013). "Safety and efficacy of ureteroscopy after obstructive pyelonephritis treatment". Int J Urol. 20 (9): 917–22. doi:10.1111/iju.12060. PMID 23347168.
- ↑ Malek RS, Elder JS (1978). "Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature". J Urol. 119 (5): 589–93. PMID 660725.
- ↑ Libre Pathology https://librepathology.org/wiki/Medical_kidney_diseases#cite_note-Ref_Sternberg5_1729-75 Accessed in Jan 24,2017
- ↑ Korkes F, Favoretto RL, Bróglio M, Silva CA, Castro MG, Perez MD (2008). "Xanthogranulomatous pyelonephritis: clinical experience with 41 cases". Urology. 71 (2): 178–80. doi:10.1016/j.urology.2007.09.026. PMID 18308077.
- ↑ Fowler JE, Perkins T (1994). "Presentation, diagnosis and treatment of renal abscesses: 1972-1988". J Urol. 151 (4): 847–51. PMID 8126807.
- ↑ 6.0 6.1 Sahin S, Resorlu B, Eksi M, Aras B, Atar A, Tugcu V (2016). "Flexible ureteroscopy versus laparoscopy for the treatment of patients who initially presented with obstructive pyelonephritis". Pak J Med Sci. 32 (3): 570–4. doi:10.12669/pjms.323.9938. PMC 4928400. PMID 27375691.
- ↑ 7.0 7.1 Das D, Pal DK (2016). "Double J stenting: A rewarding option in the management of emphysematous pyelonephritis". Urol Ann. 8 (3): 261–4. doi:10.4103/0974-7796.184881. PMC 4944615. PMID 27453644.
- ↑ Meir DB, Inoue M, Gur U, Livne PM, Yaniv Y, Tiedeman K; et al. (2004). "Urinary diversion in children with pelvic tumors". J Pediatr Surg. 39 (12): 1787–90. PMID 15616930.
- ↑ Wang HD, Zhu XF, Xu X, Li GZ, Liu N, He F; et al. (2017). "Emphysematous Pyelonephritis Treated with Vacuum Sealing Drainage". Chin Med J (Engl). 130 (2): 247–248. doi:10.4103/0366-6999.198021. PMID 28091422.