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Renal Corticomedullary Abscess Treatment & Management

  • Author: Aaron Benson, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 06, 2015
 

Medical Care

In most patients with acute focal or multifocal pyelonephritis, treatment with appropriate antibiotics should produce a clinical response within one week of initiating therapy. However, well-established large abscesses are often difficult to treat with antibiotics alone, with most studies limiting treatment of renal abscesses with antibiotics alone to lesions smaller than 3 cm.

In most patients with suspected corticomedullary abscess, a prompt attempt at treatment with intravenous antibiotics directed against culture-specific bacteria in addition to intravenous fluid resuscitation may be used. Medical treatment alone should be limited to hemodynamically stable patients with small (< 3 cm) corticomedullary abscesses. Patients with signs of hemodynamic instability due to sepsis or with large renal abscesses (≥3 cm) should undergo percutaneous or surgical drainage for abscess management (see Surgical Care). Moreover, medical therapy alone in the treatment of perinephric abscesses is inappropriate, as the risk of mortality associated with perinephric abscess treated with antibiotics alone is upward of 33%.

Comploj et al treated 6 pediatric patients conservatively with broad-spectrum antibiotics. None of the abscesses were treated surgically or percutaneously drained. In all 6 cases, the abscess was successfully resolved.[13]

Intravenous administration of a penicillin derivative, a cephalosporin, an aminoglycoside, or a fluoroquinolone is the appropriate initial medical treatment. Following sufficient resolution of nausea/vomiting and fever, antibiotics may be administered orally.

For combination therapy, a beta-lactam antibiotic plus an aminoglycoside should be administered intravenously. Administer this line of therapy until culture and sensitivity results are received and then modify the antimicrobial therapy to the most appropriate agent.

The duration of therapy is not well defined. Continue parenteral antibiotics for at least 24-48 hours after patient symptoms clinically improve and the fever resolves. Then, administer a suitable oral antibiotic medication and continue this treatment regimen for an additional 2-4 weeks, as determined by complete clinical and radiographic resolution of the intrarenal process.

Factors that may contribute to medical treatment failure include elderly age, diabetes mellitus, large abscesses, obstructive uropathy, and urosepsis.

Antimicrobial therapy alone is not indicated for patients with xanthogranulomatous pyelonephritis (XGP). Nephrectomy is required.

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Surgical Care

Surgical debridement, drainage, and nephrectomy were once widely used to treat corticomedullary abscesses. However, since the advent of effective antibiotics along with percutaneous techniques, the open surgical approach is now reserved for more severe, refractory cases.

Indications to intervene aggressively include persistent infection unresponsive to appropriate antibiotics, impending sepsis, and ongoing hemodynamic instability.

Coagulopathy is the main contraindication to percutaneous drainage or surgical intervention. In most cases, the coagulopathy can be corrected so that the appropriate therapy can be delivered.

Abscess drainage

In general, large intrarenal abscesses require drainage if the patient has persistent fever and no clinical improvement after one week of appropriate antimicrobial therapy. Percutaneous drainage plus parenteral antibiotics is indicated as the initial treatment for abscesses 3-5 cm in size. Renal abscesses may be drained percutaneously under CT or ultrasonographic guidance.

In cases that involve perirenal abscess or infected urinoma, also place a percutaneous perirenal drain. Drainage via the percutaneously placed tube should continue at least until the patient is afebrile and stable, and then until drain output is minimal.

Surgical therapy

Surgical debridement, drainage, and nephrectomy were once used widely to treat corticomedullary abscesses. Since the advent of effective antibiotics along with percutaneous techniques, the open surgical approach is now reserved for more severe, refractory cases.

If surgical intervention is indicated, the abscess should be explored and drained. Copious irrigation of the infected renal fossa with an antibiotic irrigant along with placement of perirenal drains should follow. Reserve nephrectomy for patients with diffusely damaged renal parenchyma or patients who are septic and require urgent intervention for survival.

Nephrectomy

Simple nephrectomy is usually adequate.

Partial nephrectomy may be possible in patients with focal disease confined to the kidney (stage I) or perinephric fat (stage II); however, the more common presentation is diffuse disease involving most of the kidney and extending to the perirenal fat (stage II) and beyond (stage III).

Nephrectomy is often required for patients with symptomatic XGP. Following nephrectomy, the prognosis is excellent in patients without other urinary tract pathology. The xanthogranulomatous process does not recur after excision.

Preoperative details

A thorough workup that involves screening for risk factors that predispose to intrarenal abscess is necessary. This workup should include preoperative imaging to define the extent of the parenchymal process (see Imaging Studies). Contrast CT scanning is the standard imaging modality and allows greatest definition of the patient’s anatomy, degree of abscess extension, and associated conditions (eg, obstructive uropathy). Moreover, if surgical intervention is necessary, CT imaging can be used to help determine the optimal surgical approach.

Intraoperative details

Either supine or flank positions may be used. Usually, the flank position is preferred because of ease of establishing a drainage tract and prevention of possible peritoneal exposure to infected material.

Postoperative details

Postoperative parenteral antibiotic therapy should continue following surgery, with subsequent conversion to oral administration when the patient is able to tolerate a diet.

Antibiotic therapy is generally continued for at least 2 weeks.

Discharge patients under the following conditions:

  • Tolerating diet
  • Ambulating
  • Afebrile
  • Adequate pain control on oral analgesics

Follow-up

See the list below:

  • Instruct the patient to return to the clinic in 1-2 weeks for follow-up examination.
  • Check the wound for signs of surgical-site infection.
  • Remove staples or sutures.
  • Obtain a follow-up contrast CT scan to ensure resolution of renal parenchymal abnormalities.
  • Following surgery, inform the patient that normal activities can resume in 4-6 weeks.
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Contributor Information and Disclosures
Author

Aaron Benson, MD Staff Physician, Department of Urology, Southern Illinois University School of Medicine

Aaron Benson, MD is a member of the following medical societies: American Medical Association, American Urological Association, Illinois State Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Keith Steinbecker, MD Consulting Staff, Department of Urology, St John's Mercy Medical Center

Keith Steinbecker, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Julius Lynn Teague, MD, FACS, FAAP Medical Director, Pediatric Urology, Greenville Hospital System Children's Hospital

Julius Lynn Teague, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Thomas H Tarter, MD, PhD Associate Professor, Department of Surgery, Division of Urology, Director of Urologic Oncology, Simmons Cooper Cancer Institute, Southern Illinois University School of Medicine

Thomas H Tarter, MD, PhD is a member of the following medical societies: American Medical Association, American Urological Association, Society of Urologic Oncology, American College of Surgeons Oncology Group

Disclosure: Received ownership interest from Illinois Cryotherapy Enterprise for other.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

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Contrasted CT scan that demonstrates a corticomedullary abscess in a 27-year-old patient with diabetes mellitus who has a history of multiple urinary tract infections. Note the heterogeneous hypodense lesion in the right kidney. Extracapsular extension is not present.
 
 
 
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