Xanthogranulomatous Pyelonephritis Treatment & Management
- Author: Samuel G Deem, DO; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Xanthogranulomatous pyelonephritis (XGP) is a surgically managed disease that is treated with either nephrectomy or, in rare circumstances, partial nephrectomy. Antibiotics are used in all cases, but medical care rarely suffices for treatment.
Extirpation is necessary because the disease occurs or results in an infected, nonfunctioning kidney. Nephron-sparing surgery will continue to be explored, provided that viable renal parenchyma is demonstrated. Now that laparoscopic nephrectomy is the criterion standard in many regions, this approach can be entertained depending on the individual surgeon’s skill level.
Contraindications to surgical therapy of XGP are those consistent with all major operations and intolerance to anesthesia, uncorrected coagulopathy, and severe connective-tissue disorders.
Annual imaging of the contralateral urinary tract is important. Aggressively treat all urinary tract infections. If possible, eliminate or control the agent or illness that is predisposing the patient to XGP. Evaluation of lower urinary tract pathology and voiding dysfunction may be important in these patients.
Medical therapy has proven sufficient for treatment of XGP in only a handful of cases. Antibiotics may be appropriate as a temporizing measure in patients who require a medical workup before nephrectomy. Similarly, appropriate prophylactic antibiotics should be administered before operative intervention.
The choice of antibiotic should be geared toward the identity and sensitivity of the organism. Proteus organisms and E coli are usually sensitive to various antibiotics, including first-generation cephalosporins and trimethoprim-sulfamethoxazole. Pseudomonas species have a narrower spectrum to which they are sensitive, however, and may require the use of aminoglycosides, third-generation cephalosporins, or fluoroquinolones.
In patients who are not in a septic state and who have been evaluated on an outpatient basis, the author’s preference is to use an oral antibiotic until surgery, at which point IV antibiotics may be administered. Guidelines have not been established regarding the duration of antibiotic therapy after nephrectomy, but the author usually continues an active oral agent for 1 week.
Nephrectomy is the criterion standard of treatment for XGP. Cases of XGP are often challenging, particularly in patients with local organ involvement. The goal is to remove all involved granulomatous tissue. If this is not accomplished, the remaining infected tissue may lead to cutaneous fistulae. Some authors have advocated a role for partial nephrectomy if the disease is limited and therefore amenable to this operation.
Laparoscopic nephrectomy is feasible for certain cases of XGP. Small pediatric series of XGP have reported success with this technique. However, Bercowsky et al reported that the technical difficulty and associated complications of the procedure negated any benefits over open nephrectomy. The increased use of hand-assisted laparoscopic nephrectomy may allow a reasonable compromise between technical feasibility and acceptable patient morbidity.
Shah and colleagues, in a retrospective analysis of 37 patients with XGP treated with either with either open (n=20) or laparoscopic nephrectomy (n=17), found that laparoscopic surgery was associated with lower mean blood loss, a shorter mean hospital stay, and a lower complication rate. Conversion to open surgery was necessary in one laparoscopic nephrectomy patient.
When use of the laparoscopic approach is being entertained, the patient and his or her family should be informed that a conversion rate of nearly 50% can be expected.
Appropriate preoperative imaging studies are essential. This is best accomplished with CT scanning. Administer bowel preparation and preoperative antibiotics. Ensure that surgical consent includes provisions for the possibility of operation on adjacent organs. If the patient is diabetic, establish control of hyperglycemia preoperatively. Correct any preexisting coagulopathy.
Intraoperatively, a flank approach through the appropriate intercostal/subcostal space (often the 11th rib) is desirable to avoid contamination of the peritoneum. Transabdominal subcostal exposure may be unavoidable if adjacent organs are involved with the mass.
The basic principles of nephrectomy apply to the extirpation of renal XGP. If possible, a radical nephrectomy (including Gerota’s fascia) should be performed, since the mass may still represent a neoplasm. All involved tissue must be removed. Liberal irrigation with antibiotic fluid is performed, and a suction drain is left in place.
Immediate postoperative care for patients with XGP is consistent with that for patients who have undergone standard nephrectomy. Watch for signs of sepsis. Institute aggressive pulmonary toilet. Encourage early ambulation.
The urologic surgeon should maintain a low threshold for involving a general surgeon in the management of XGP patients. Bleeding should be aggressively controlled. On the left side, splenic injury may result; if possible, preservation of the spleen should be attempted. Any pancreatic injuries must be identified, repaired, and appropriately drained.
On the right side, injuries may occur to the duodenum and liver. Liver lacerations during nephrectomy are frequently limited to capsular tears, which may be easily controlled with argon-beam coagulation and pressure. Duodenal injuries necessitate repair and nasogastric and cutaneous drainage. The colon is vulnerable to injury on either side. In a patient who has received adequate bowel preparation, these colonic injuries typically can be repaired primarily.
Vascular injury, especially on the right side, that involves the inferior vena cava can be humbling. The right-side processes are often highly inflamed and may involve the adrenal and gonadal veins in such a way as to render them vulnerable to avulsion and injury. Great care must be taken in dissecting out the right renal hilum. An alternative is to cross-clamp the hilum, transect it, and oversew the entire bundle. This approach can be planned or used in an emergency.
Postoperative abscess and cutaneous fistulization may occur, often after the drain has been removed and the patient has been discharged from the hospital. Patients typically present with drainage from the wound and fevers. CT scanning and percutaneous drainage should be performed, along with administration of IV antibiotics.
Schlagenhaufer F. Uber eigentumlich staphylomykosender neiven und des pararenalen bindegewebes. Frankfurt Z Pathol. 1916. 19:139-48.
Peréz LM, Thrasher JB, Anderson EE. Successful management of bilateral xanthogranulomatous pyelonephritis by bilateral partial nephrectomy. J Urol. 1993 Jan. 149(1):100-2. [Medline].
Kuo CC, Wu CF, Huang CC, et al. Xanthogranulomatous pyelonephritis: critical analysis of 30 patients. Int Urol Nephrol. 2011 Mar. 43(1):15-22. [Medline].
Malek RS, Elder JS. Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature. J Urol. 1978 May. 119(5):589-93. [Medline].
Gregg CR, Rogers TE, Munford RS. Xanthogranulomatous pyelonephritis. Curr Clin Top Infect Dis. 1999. 19:287-304.
Kim SW, Yoon BI, Ha US, Sohn DW, Cho YH. Xanthogranulomatous pyelonephritis: clinical experience with 21 cases. J Infect Chemother. 2013 Dec. 19(6):1221-4. [Medline].
Hitti W, Drachenberg C, Cooper M, et al. Xanthogranulomatous pyelonephritis in a renal allograft associated with xanthogranulomatous diverticulitis: report of the first case and review of the literature. Nephrol Dial Transplant. 2007 Nov. 22(11):3344-7. [Medline].
Loffroy R, Guiu B, Varbédian O, Michel F, Sagot P, Cercueil JP, et al. Diffuse xanthogranulomatous pyelonephritis with psoas abscess in a pregnant woman. Can J Urol. 2007 Apr. 14(2):3507-9. [Medline].
Inouye BM, Chiang G, Newbury RO, Holmes N. Adolescent xanthogranulomatous pyelonephritis mimicking renal cell carcinoma on urine cytology: an atypical presentation. Urology. 2013 Apr. 81(4):885-7. [Medline].
Tiguert R, Gheiler EL, Yousif R, et al. Focal xanthogranulomatous pyelonephritis presenting as a renal tumor with vena caval thrombus. J Urol. 1998 Jul. 160(1):117-8. [Medline].
Shah HN, Jain P, Chibber PJ. Renal tuberculosis simulating xanthogranulomatous pyelonephritis with contagious hepatic involvement. Int J Urol. 2006 Jan. 13(1):67-8. [Medline].
Osca JM, Peiro MJ, Rodrigo M, Martinez-Jabaloyas JM, Jimenez-Cruz JF. Focal xanthogranulomatous pyelonephritis: partial nephrectomy as definitive treatment. Eur Urol. 1997. 32(3):375-9. [Medline].
Bercowsky E, Shalhav AL, Portis A, Elbahnasy AM, McDougall EM, Clayman RV. Is the laparoscopic approach justified in patients with xanthogranulomatous pyelonephritis?. Urology. 1999 Sep. 54(3):437-42; discussion 442-3. [Medline].
Mahesan N, Choudhury SM, Khan MS, et al. One hand is better than two: conversion from pure laparoscopic to the hand-assisted approach during difficult nephrectomy. Ann R Coll Surg Engl. 2011 Apr. 93(3):229-31. [Medline].
Shah KJ, Ganpule AP, Kurien A, Muthu V, Sabnis RB, Desai MR. Laparoscopic versus open nephrectomy for xanthogranulomatous pyelonephritis: An outcome analysis. Indian J Urol. 2011 Oct. 27(4):470-4. [Medline]. [Full Text].
American Urological Association. Best Practice Policy Statement on Urologic Surgery Antimicrobial Prophylaxis. Available at http://www.auanet.org/content/media/antimicroprop08.pdf.