eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions
Xanthogranulomatous Pyelonephritis: Treatment
Updated: Jun 11, 2008
Treatment
Medical Therapy
Medical therapy has proven sufficient for treatment of xanthogranulomatous pyelonephritis (XGP) in only a handful of cases. Antibiotics may be appropriate as a temporizing measure in patients who require a medical workup prior to nephrectomy. Similarly, appropriate antibiotics should be administered prior to 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 septic and who have been evaluated on an outpatient basis, the author's preference is to use an oral antibiotic until surgery, when intravenous 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.
Surgical Therapy
Nephrectomy is the criterion standard of treatment for XGP. These are often challenging cases, 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.7
Laparoscopic nephrectomy is feasible for certain cases of XGP. Small pediatric series of XGP have reported success with the laparoscopic technique. However, Bercowsky et al reported that the technical difficulty and associated complications of the procedure negated any benefits over open nephrectomy.8 The increased use of hand-assisted laparoscopic nephrectomy may allow for an acceptable compromise between technical feasibility and acceptable patient morbidity. The laparoscopic approach may be entertained in all cases, but the patient and the patient's family can expect a conversion rate of nearly 50%.
Preoperative Details
- Appropriate preoperative imaging studies are essential. This is best accomplished with CT scanning.
- Administer a bowel preparation and preoperative antibiotics.
- Surgical consent should include provisions for the possibility of operation on adjacent organs.
- If the patient is diabetic, establish control of hyperglycemia prior to surgery.
- Correct any preexisting coagulopathy.
Intraoperative Details
A flank approach through the appropriate intercostal/subcostal 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 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.
Postoperative Details
The immediate postoperative care for patients with XGP is consistent with care that follows standard nephrectomy.
- Watch for signs of sepsis.
- Institute aggressive pulmonary toilet.
- Encourage early ambulation.
Follow-up
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.
Complications
The urological surgeon should maintain a low threshold to involve a general surgeon in patients with xanthogranulomatous pyelonephritis (XGP). Bleeding should be aggressively controlled. On the left, splenic injury may result; if possible, preservation of the spleen should be attempted. Any pancreatic injuries must be identified, repaired, and appropriately drained.
Similarly, right-sided 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 require repair and nasogastric and cutaneous drainage. The colon is vulnerable to injury on either side. A patient who has received adequate bowel preparation may typically have these colonic injuries primarily repaired.
Vascular injury, especially on the right side, that involves the inferior vena cava can be humbling. The right-sided processes are often very inflamed and stuck, involving the adrenal and gonadal veins, lending them to avulsion and injury. Great care must be taken when dissecting out the right renal hilum. An alternative is to cross-clamp the hilum, transect it, and oversew the entire bundle. This 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 intravenous antibiotics.
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| Workup: Xanthogranulomatous Pyelonephritis |
 Treatment: Xanthogranulomatous Pyelonephritis |
| Follow-up: Xanthogranulomatous Pyelonephritis |
| Multimedia: Xanthogranulomatous Pyelonephritis |
| References |
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References
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Further Reading
Keywords
xanthogranulomatous pyelonephritis, XGP, infectious renal phlegmon, long-term renal obstruction, renal cell carcinoma, nephrectomy, pyelocutaneous fistulae, ureterocutaneous fistulae, pyeloenteric fistulae
