Fulminant emphysematous pyelonephrhitis (EPN) managed by percutaneous drainage (PCD): a case series

Abstract

Purpose: Emphysematous pyelonephritis is a rare, severe gas-forming infection of the kidney resulted in high operative mortality. Newer literatures suggested percutaneous drainage, as compared to the standard nephrectomy, as a better modality. We reported three cases of EPN in 2008-2010, which were successfully managed by combined PCD and medical treatment. Materials and methods: Three ladies with median age of 61 (58-66) were admitted to Queen Elizabeth Hospital for loin pain and fever. All of them developed urosepsis with shock requiring ICU admission. Computer Topography showed emphysematous pyelonephritis. (one Class I, one Class 3A, one Class 3B, Huang model) Emergency percutaneous drainage by either radiologist or urologist was performed. Results: 1.Case of Class 3B emphysematous pyelonephritis had a Fr 10 Flexima drain inserted by a radiologist to the retroperitoneal space. Along with medical treatment in ICU, her condition improved. Follow-up CT scan at 4th week showing resolving gas pockets. Another follow-up CT scan at 16th week showing complete resolution of gas pockets and the catheter was removed. At the latest follow-up at 15th month, she had fully recovered with a normal renal function. 2.Case of Class 3A emphysematous pyelonephritis was further complicated with acute myocardial infarction. Emergency drainage under general anaesthesia was performed by a urologist and a urology trainee. Three 10 Fr Malecot catheters were inserted to the perinephric space. Along with medical treatment in ICU, her condition improved. Follow-up CT scan at 1st week reported 3 catheters in situ. All Malecot catheters were removed on post-op Day 11. CT at 6th and 16th week reported decreased size of left kidney collections. Complete resolution of renal collection was reported on CT at 10th month. Upon the latest follow-up at 11th month, she had fully recovered with a normal renal function. 3.Case of Class 1 emphysematous pyelonephritis had a Fr 14 malecot catheter inserted by a urologist and urology trainee under LA to the collecting system. Along with medical treatment in ICU, her condition improved. Follow-up CT scan at 3rd week showing resolution of gas pockets and an obstructing ureteric stone. Ureterosocpic lithotripsy was performed at 4th week with stone clearance. A ureteric stent was inserted and the percutaneous drain removed. Upon the latest follow-up, she had fully recovered with a normal renal function. Conclusion: Emphysematous pyelonephritis is a urological emergency. Patients are usually diabetic middle aged ladies presented with urosepsis and septic shock. Previous gold standard of treatment was emergency nephrectomy. However risk of major surgery is high for this group of patients. Hence, with the advances of percutaneous access, percutaneous drainage becomes the new gold standard of management of emphysematous pyelonephritis. In conclusion, with the advance of image guided drainage, percutaneous drainage should be the new gold standard for the management of emphysematous pyelonephritis.