Minimally invasive techniques as a first line approach in the management of emphysematous pyelonephritis - A single centre experience

Abstract

Context: Emphysematous pyelonephritis (EPN) is a dangerous necrotizing infection of the kidney involving the diabetics with a high case fatality rate. Recent medical literature has shown shifting of treatment strategy from conventional radical approach to minimally invasive approach. Aims: The aim of our study was to assess the role of minimally invasive stepwise decompression techniques in the management of EPN and preservation of the renal unit. Settings and Design : This was a retrospective observational study conducted from June 2017 to April 2020 at a tertiary care centre. Material and Methods: We reviewed the hospital online records of 18 patients diagnosed with EPN for patient demographics, clinical profiles, co-morbidities, laboratory and, radiological investigations, surgical interventions performed and the outcomes. The severity of EPN was graded as per the Huang classification. Patients underwent surgical interventions as per the treatment protocol and response was assessed. Statistical Analysis Used: Descriptive statistics was applied. Results: Diabetes mellitus was present in 15 (83.3%) patients along with urinary tract obstruction in 8 (44.4%) patients. Flank pain (77.7%) was the most common presenting clinical feature while Escherichia coli (55.5%) were the most common causative organism. Most patients (50%) had Type- II EPN, all of which were managed successfully by minimally invasive procedures. In total seventeen patients (94.4%) responded well while one patient (5.5%) underwent nephrectomy with no mortality. Conclusions: Renal salvage in EPN requires multidisciplinary approach including the initial medical management followed by properly selected stepwise decompressive surgical techniques. Conservative management and decompression techniques have shown to improve patient's outcome, reducing the traditional morbidity associated with nephrectomy.

Is there still a role of nephrectomy in management of emphysematous pyelonephritis in today's era?

“…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[ 1 ] 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.…”

“…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. [ 1 ]…”

“…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[ 1 ] have considered primary internal drainage with placement of the ureteral double J (DJ) stent in all patients preferably under local anesthesia.…”