Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review

• Emphysematous pyelonephritis (EPN) is a life threatening necrotising infection of the renal/perirenal tissue mainly seen in poorly controlled diabetic patients. Urological intervention is required to relieve obstructive uropathy.
• CT has 100% sensitivity and should be the imaging modality of choice for diagnosis, classification and prognostic scoring.
• Percutaneous catheter drainage and medical management have improved survival rates. Overall mortality has dropped from 50% to 18%.
• Septic shock, rising creatinine, thrombocytopaenia, Wan’s type 1 EPN, disturbance of consciousness and bilateral EPN are indicators of poor prognosis.
• Emergency nephrectomy should be reserved for severe EPN.

IntroductionEmphysematous pyelonephritis (EPN) is a life-threatening urological emergency. A high index of suspicion is required for diagnosis as such patients may present to physicians with typical features of pyelonephritis.Presentation of caseA 67 year old lady presented atypically to the Emergency Department with symptoms of renal colic. The diagnosis of emphysematous pyelonephritis was established on prompt CT scanning. She did not respond to conservative management. Due to acute, critical deterioration, she underwent a radical right nephroureterectomy. The resected kidney involved a long segment of necrotic, gangrenous ureter. The patient had a smooth post-operative recovery and was successfully discharged. She remains well on follow-up after one year.DiscussionEarly radiological diagnosis is imperative for risk stratification of EPN. Current evidence recommends percutaneous catheter drainage with interval nephrectomy as the gold standard treatment. We review the literature for pathophysiology and clinical prognostic factors. This case adds onto the limited evidence base on ureteric involvement in EPN, suggesting a revision of EPN classification.ConclusionFurther research on ureteric involvement and treatment outcomes in EPN is required. Even in the current era of minimally invasive surgery and renal preservation therapies, early open nephrectomy still has a role in the management of EPN.