Is there still a role of nephrectomy in management of emphysematous pyelonephritis in today's era?
Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, United States
H N Shah
Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
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Shah H N. Is there still a role of nephrectomy in management of emphysematous pyelonephritis in today's era?.J Postgrad Med 2021;67:130-131
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Shah H N. Is there still a role of nephrectomy in management of emphysematous pyelonephritis in today's era?. J Postgrad Med [serial online] 2021 [cited 2021 Dec 4 ];67:130-131
Available from: https://www.jpgmonline.com/text.asp?2021/67/3/130/324238
Emphysematous pyelonephritis (EPN) refers to a necrotizing gas-forming infection of the renal parenchyma, the urinary tract system, and perirenal tissue and is most commonly seen in patients with poor glycemic control. In the present issue of the journal, Gite et al have published a retrospective single-center study focusing on the outcomes of a multi-disciplinary approach in the management of EPN. The authors have concluded that their approach, prioritizing renal preservation through conservative management and stepwise renal decompression not only resulted in improved patient outcomes but also reduced the traditional morbidity and mortality associated with early nephrectomy.
Although Schultz and Klorfein who coined the term EPN recommended against open surgical drainage of multiple cortical abscesses, it was later noted that diabetic patients treated with surgical drainage or nephrectomy experienced a lower mortality rate of 35% when compared with the 75% mortality rate in patients treated conservatively. Thereafter, open surgical intervention continued to play a central role in the management of EPN. Although early nephrectomy was still practiced for patients with extensive EPN and associated risk factors for mortality, it was found to be associated with high mortality.,
In 1986, Hudson et al., encountered a gravely ill patient with multiple co-morbidities who was determined to be an extremely high-risk candidate for a nephrectomy. Instead, they placed a nephrostomy tube and found it to be a life-saving alternative to open surgical drainage or nephrectomy. This gave birth to the era of minimally invasive surgical intervention for EPN. A decade after the publication of this case report, Chen, et al., noted that 80% of patients responded well to combined therapy with antibiotics and computed tomography guided percutaneous drainage and recommended it as an acceptable alternative to antibiotic therapy with open surgical intervention. The conservative approach with minimally invasive drainage was found to salvage kidneys in 90% of patients with an overall survival rate of 100%. With the adoption of minimally invasive renal drainage, nephrectomy was reserved only for the patients with progressive disease or those deemed to be having refractory sepsis inspite of initial renal salvaging measures.
The first step in management of EPN should include resuscitation with adequate hydration, broad spectrum parenteral antibiotics targeting gram-negative bacteria, correction of electrolyte and acid-base disturbances and careful control of blood sugar. Inotropic support might be needed if fluid resuscitation is insufficient in correction of hypotension. In real life, resuscitation would have started in a hemodynamically unstable patient even before the radiological diagnosis of EPN is made. Even a conservative approach to treatment often requires multi-disciplinary collaboration between an endocrinologist, urologist, interventional radiologist, and intensivist.
Prompt surgical drainage should be considered immediately after stabilization of a patient's cardiopulmonary status. The minimally invasive renal drainage approach involves placement of ureteric stent and/or percutaneous drainage and may also require multiple tubes in selected patients to ensure maximal renal drainage. Gite et al have considered primary internal drainage with placement of the ureteral double J (DJ) stent in all patients preferably under local anesthesia.
Although internal drainage might be useful in patients with ureteral obstruction and resultant hydronephrosis, it may not drain intrarenal or peri-nephric abscess. It also involves shifting the patient in the operating room with administration of general or regional anesthesia since the placement of a ureteral DJ stent under local anesthesia might cause significant pain especially in male patients. Usually, a retrograde pyelogram is performed prior to placement of a stent to provide an anatomical road map. Aspirating the urine from the renal pelvis and sending it for culture is recommended. Only after draining the renal pelvis, a minimum quantity of half-diluted contrast should be instilled to delineate a calyx; thereby assisting proper placement of the proximal end of the stent. Instilling contrast under pressure might worsen septicemia and endotoxemia due to pyelo-venous and pyelo-lymphatic back-flow.
Conversely, in a critically ill patient, the placement of a nephrostomy tube although more invasive can be done at bedside under local anesthesia. It also provides better renal decompression that is much needed in a critically ill patient. Hence the decision about internal versus external drainage should be personalized based on a patient's hemodynamic status coupled with radiological and biochemical parameters.
Since patients with diabetes are at higher risk for chronic kidney disease, nephron-sparing treatment should be the goal. However even in the modern era, one does come across patients who present late with multiple co-morbidities and remain refractory to conservative management. These patients should be promptly identified and offered the benefit of a nephrectomy as a life-saving rescue therapy.
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